Total joints in ASCs: 3 orthopedic surgeons answer 6 big questions

Total joint replacements are increasingly moving to the outpatient setting.

Three orthopedic surgeons answer six questions on total joints in ASCs. See all three at the Future of Spine + Spine, Orthopedic & Pain Management-Driven ASC Conference in Chicago June 14-16, 2018. Registration still open – click here.

Question: How has the adoption of outpatient surgery helped and/or hindered total joint cases?

Michael Chmell, MD. OrthoIllinois (Rockford): It has helped and been a benefit. It has been a benefit to the patient because they have an overall [better] experience in a surgery center than a hospital. There are also potentially lower complication rates and risk of infection compared to undergoing total joint replacement in the hospital.
Doing total joints in a surgery center is positive for the surgeons because they get to work with staff they are familiar with to create more efficiency. In hospitals physicians are not always working with the same staff day in and day out. And for the surgery center it is a huge positive because it is a new source for patient volume and revenue that was not present five to 10 years ago.

Total joint cases can use extensive instrumentations that other surgeries do not require. At the surgery center, we are trying to have surgeons cut down on the amount of equipment because of the lack of storage space and washing space. Additionally, doing bigger cases results in patients staying longer. Surgery centers then have to adjust schedules to accommodate the number of patients with the number of beds available.

Q: What trends do you see between joint replacement patients and outpatient surgery centers?

MC: More patients will continue to look for centers that do outpatient joints. I am hopeful that as a [physician practicing at a] freestanding non-hospital surgery center, we will eventually treat Medicare patients at our surgery centers. The other trend going forward is trying to have a uniformity of vendors, where all implants come from a single vendor. This will help with space and sterilization issues and improve staff efficiency.

Q: What is the biggest roadblock you see to a nationwide trend of total joints being performed in the ASC? How can the industry jump-start more total joint centers?

T.K. Miller, MD. Carilion Clinic (Roanoke, Va.): From a fiscal perspective, centers are still limited by CMS constraints, although that seems to be changing with the expected permission to perform total knees in ASCs. With the realization that for select patients, nonhospital-based care represents fiscal responsibility and optimized use of resources, it is reasonable to expect other arthroplasty procedures will receive CMS approval to be performed in the ASC environment. Until that time, successful centers will need to continue to validate the net value (not just upfront cost, but also quality meeting or exceeding hospital-based services) as they develop viable contractual relationships with commercial carriers and large self-insured entities.

With strict perioperative protocols and realistic patient selection, from a global cost perspective, freestanding ASCs can be expected to be seen as the more fiscally appropriate sites of care, rather than hospital-associated ambulatory sites for a large number of patients. Industry support in the form of cost-competitive implants, DME supplies and other procedure and perioperative-based expenses (perhaps as a total joint "package") will allow centers "on the fence" to perform fiscal reviews and may engage sites not currently willing to assume the financial risk of developing and advancing a program.

Q: Where do you see the biggest opportunity for growth among total joint programs at ASCs? Where can orthopedic ASCs grow the most over the next 5 years?

TM: Expansion of operative services to include anterior-approach total hips seems to be the procedure that best fits patient profiles, pain management requirements, immediate perioperative needs and ambulatory ability post-procedure, and should be a prime opportunity for growth.

Shoulder arthroplasty is also an underconsidered procedure at this time. The other site of growth continues with spine. Not just limited exposure and single-level intervention, but extended level fusion, especially if extended stay or 23-hour capability is included.

Q: What major trends are shaping the orthopedic field and how can orthopedic surgeons thrive as healthcare continues to shift to a value-based payment model?

Nitkin Khanna, MD. Orthopaedic Specialists of Northwest Indiana (Munster): The move to outpatient surgery and independent orthopedic practice will be major drivers over the next 10 years. Physician autonomy and "patient first" care cannot be accomplished under a hospital employed model. Physician satisfaction scores and patient care will always be better with physician empowerment as physicians are the only stakeholder that has pledged an oath to the patient. In spite of what the system wants, the patients are not happy with the new corporate medicine approach and they want to be able to connect and have continuity with their doctor.

Q: What new partnerships/ancillary services are orthopedic surgeons eyeing and have you forged any partnerships that have reaped successful at Orthopaedic Specialists of Northwest Indiana?

NK: In order to maintain independence, it is key to be able to derive income from ancillary revenue streams to offset huge overhead costs. Managing these more cost-effective and higher quality ancillary services is key to ensuring they provide a net benefit to the organization. We are now seeing insurance companies recommend that patients seek these services from our physicians and our office-based services as the quality and costs are far superior. This drive towards a more sensible and transparent system seems intuitive.

Further, it will be the responsibility of the independent orthopedic groups to align with current hospital systems to provide services for their captured patients. Independent groups will also need to directly market their services to the patient in order to maintain their market share.

More articles on orthopedics:
Total joints in ASCs: 4 common questions answered
Stryker CEO sees orthopedics moving to ASCs—But how fast?
Total joints in ASCs—key challenges, opportunities


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