Projections say 51% of total joints will be outpatient by 2026 — will they be correct? Key thoughts from Dr. Steve Lucey

Total knee and hip replacements are moving into the outpatient setting, but the transition may be slower than expected.

Sg2 reported 15 percent of total joint replacements were performed in the outpatient setting in 2017 and predicted 26 percent would be performed there in 2018. The firm expects 51 percent of total joint replacements to be outpatient by 2026. 

But in most cases, surgeons are still performing a majority of their joint replacements in the inpatient setting, even if the patient would be a good candidate for outpatient surgery. Here, Steve Lucey, MD, an orthopedic surgeon in Greensboro, N.C., discusses the roadblocks to transitioning total joints into the outpatient setting and what to expect going forward.

Question: What challenges are there for surgeons to take their cases outpatient?

Dr. Steve Lucey: Until you align incentives of all parties involved, you aren't going to see the site of service shift for total joint replacements to the ASC setting. There are several factors that the non-clinical people don't think about. It takes an incredible amount of work and overhead cost to shift the patient to the outpatient surgical setting because the infrastructure often doesn't exist around the recovery process like it does in the hospital. The hospital has a therapy, case management and scheduling departments to support them. The ASC doesn't have these departments for patient navigation, so it's much more difficult. The surgeon has to hire case managers, create thorough patient education material, and acquire tools (such as an informatics platform) that identify appropriate candidates and follow them though the 90 day episode. Additionally, they have to collect patient outcomes and, in many cases, take risk and figure how to handle that risk.

Q: You have been able to take total joint replacements to the outpatient setting, as well as a number of other pioneering surgeons across the country. What is the difference?

SL: My group has done over 450 outpatient joints under 90 day prospective bundled payments. It is relatively simple to get the mid-volume surgeons who are used to doing cases in the ASC. However, it’s more challenging to get the high-volume joint replacement surgeons that perform all their cases in the hospital to consider the ASC. If the surgeon isn't an owner in the ASC, and the ASC doesn't have a support system for total joint replacement patients, it's challenging to convince those surgeons that the ASC can set systems in place to care for their patients and give them the support they need, especially if they are to deliver a concierge level of care for the entire 90 day episode.

ASCs with a clinical program that incorporates case management and patient care could be attractive to those surgeons. We started Delta Joint Management with four total joint specialists from three different practices in Greensboro, N.C., and we created a clinical platform for the program. We all hired case management specialists and implemented an informatics platform that has inclusion criteria for the patient, develops a plan of care for each bundle and measures patient reported outcomes throughout the episode of care. The entire program was catered to the high-volume joint replacement surgeons.

Those surgeons were excited to participate in creating our value-based bundled program and we managed to figure out how to shift the volume into the outpatient setting.

Q: Your bundled payments are physician-led. Why is that so important?

SL: We felt if physicians led the bundled payment efforts, both the clinical and financial decisions would be made by the surgeons for the benefit of our patients. We put every decision through a value filter; any change has to improve outcomes or decrease costs. We are at full risk, so if there is an issue, we pay for it. If there is savings, we realize the reward and pass on the savings to the surgeons via a metric-based model. It's a really powerful tool because surgeons are most concerned about their patients and the practice's reputation of caring for patients.

There is a very magical thing that occurs when you put a person in charge of the money whose reputation is based on patient care. That person is going to make sure people aren't bilking the system or doing too many procedures at the wrong site of service.

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