Total joints in ASCs — key challenges, opportunities from Dr. Michael Chmell

Michael Chmell, MD, an orthopedic surgeon with OrthoIllinois, discusses outpatient total joint replacements in ASCs and where he sees the biggest opportunities in the future.

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Question: What is the biggest challenge for total joint replacements in ASCs?

Dr. Michael Chmell: The first big challenge is achieving insurance contracting and fee schedule for outpatient total joints. Medicare hasn't covered them yet and a lot of insurers typically cover a percentage of Medicare. One of the things we had to do over the past year was get in front of our major private insurance companies to tell them what we can do. Having a track record to demonstrate to the insurance company that total joints in ASCs can be done safety was important. We showed we could do it at the hospital before taking those cases to the ASC.

The other challenge in launching total joints in our ASC has been organizing everyone and making sure we were all on the same page. We have done outpatient total joints now for two years, but early on we had to get organized with our DME, walkers and other supplies patients needed. If the cases were in the hospital, the hospital would have that equipment ready for them, but we didn't have that already in the ASC. We also had to make sure the patients had physical therapy and home health services after surgery.

All of that had to be set up 10 days preoperatively or the case couldn't be done. I did several cases at the hospital outpatient, but I hadn't thought of everything that had to happen on the day of surgery.

All of our patients now see a therapist preoperatively to get the walker and learn how to use it before the procedure.

Q: Were there any supply issues in adding total joints?

CM: Total joints are much bigger cases than the knee arthroscopy and other outpatient procedures, so having space for sterilization and storage of implants has become an issue. One way we've handled that is going through the single vendor model where all specialties in orthopedics go through a single vendor. We use 80 percent of our products from one vendor and think that's important for us to optimize space and cost.

The same people are there for every case with our products and the staff are all very familiar with those products.

Q: How does patient education factor into successful total joints at ASCs?

MC: The ideal patient is educatable and has support at home. Patients need good health and low risk; we do a risk assessment protocol where our team of case managers conducts interviews with patients about their health status and whether they have assistance at home. We learn about their bad habits and identify their risk assessment score as to whether they would be a good candidate for surgery at the ASC. An ASC doesn't want to start doing total joints for a private insurer and then have readmissions to the hospital.

The other essential element is a high quality staff. The staff are contacting the patients the night of surgery and patients always need to have someone to call when they have difficulties.

Q: How do you see total joints in ASCs growing in the future?

MC: Right now we are looking at bundled payments with private insurers. We have been doing BPCI since it started for the whole 90-day experience from the day of surgery to preop management to home health and physical therapy with one patient. We started the risk assessments because we didn't want those patients to be readmitted under the bundle.

Hopefully Medicare will allow us to transition outpatient total joint replacements to ASCs. I have many patient who would qualify for outpatient total joints at the ASC and want to go there but can't because Medicare doesn't allow it. We are considering a 23-hour stay right now; we've done around 200 total hips and knees combined and all have gone home the day of surgery. We don't have the physical space for it yet, but that's something we are considering.


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