Total joints in ASCs — Success with high-volume surgeons and the potential for Medicare patients

Altoona, Pa.-based University Orthopedics Center has successfully worked with high volume total joint replacement surgeons to bring cases into the practice's Altoona location, where more than 1,000 total joints have been performed.

Here, Christopher McClellan, MD, discusses the practice's strategy and why he's excited about the future of total joints in ASCs.

Question: How has your program evolved over the years?

Christopher McClellan: We've changed our protocols after asking patients what they would do differently. Their input has invoked change. We put our focus around the patient; our surgeries are the same as in the hospital, but it's what we do before and after surgery that is different. I work with anesthesia and the nursing team to develop the care plan for patients.

Q: What do you do differently during the postoperative period knowing patients will return home shortly after surgery?

CM: We work with a few different home health agencies. Years ago, we connected with them about starting an outpatient total joint replacement program and brought them on board. When patients come in for a knee replacement, they meet with the staff and schedule a surgical date. At that point, the scheduler contacts the home agency and provides the surgical date and insurance information because the agency bills separately. Then on the day of surgery, after the procedure is finished, our ASC staff contacts the home agency about 45 minutes before the patient leaves so that when they arrive home, the agency representatives are waiting for the patient in their driveway.

We also have the patient's medications delivered to the ASC beforehand so we can send patients home with everything they will need for recovery. It took us a year or two to finalize the protocol and we are still making changes based on patient suggestions.

Q: Do you think CMS' proposal to add total joint replacements to the ASC payable list will be good or bad for centers in the future?

CM: We are ecstatic about the possibility of CMS allowing total joints into the ASC. Right now we are limited in the number of patients we can bring to the center based on our commercial payer contracts for total joint replacements. Those patients love the program and can return home within four hours after surgery. If CMS does allow total joints in ASCs, we will be able to take more patients there, experience fewer complications and boost the overall experience for Medicare beneficiaries.

Q: What percentage of your Medicare patients do you think would be good candidates for the ASC?

CM: I think around 80 percent to 85 percent of my Medicare patients would be able to have their procedures outpatient. It's more about the mindset than anything. The reason surgeons keep otherwise healthy patients overnight is lack of coordination, expectations or worry. The patients get up at the hospital and walk around right after surgery, but they still stay overnight. However, if you prepare people to go home the same day, most patients prefer to do that. There is a misconception out there that knee replacements are a massive operation and patients have to be in bed for a week. But once we educate our patients, we see about 90 percent conversion rate to outpatient.

Q: If CMS does approve total joints for the ASC payable list, are you concerned that the potential low payment rate could push down commercial payer rates as well?

CM: No, I think we would be able to negotiate similar rates to what we have now. We are already the low-cost provider in our area and I think we would maintain our contracts. The commercial payers realize we are low cost now, so they want to make sure we can still perform those procedures in the ASC and they won't go back to the hospital. We have a really good relationship with the local payers because we can keep costs down for them.

Q: Do you anticipate bundling payments for total joint replacements in the future?

CM: I'm hoping we will be able to negotiate bundled payments; we've been ready for that. We went through the convener process to become part of the BPCI, but then realized our costs were already so low that it wouldn't help us at all. We know our costs. If someone pays in cash, it cost around $13,000 including the surgical fee, implants, anesthesia, surgery center, a month of physical therapy and medications, as compared to hospitals, where it could cost $21,000 to $50,000 for surgery alone.

Q: How do you approach data management and collection?

CM: We use our EMR as best we can, but still a lot of our information is on paper for the ASC. We give patients paper to fill out. There are so many systems that we don't know what to do with them yet. We look at the data annually as well as patient readmissions, complications and satisfaction.

 

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