By Don Sadler
A growing number of total joint surgeries are now being performed in the outpatient setting, including ambulatory surgery centers (ASCs). The proportion of elective total joint arthroplasty (TJA) procedures in which patients went home on the same day skyrocketed from less than one percent of patients in 2017 to more than 30% of patients in 2021, according to The Journal of Arthroplasty.
The increase in outpatient TJA is attributed to advancements in medical techniques and devices, as well as a growing body of research indicating the safety and cost-saving benefits of outpatient TJA.
Future savings, however, may be threatened by Medicare policies that struggle to keep reimbursement in line with the rising cost of labor and supplies and limit Medicare beneficiaries’ access to outpatient surgical care in ASCs.
Moving TKA and THA Off the IPO List
Migration of TJA to outpatient sites started many years before the COVID-19 pandemic and accelerated when the Centers for Medicare & Medicaid Services (CMS) moved total knee arthroplasty (TKA) off the inpatient-only list (IPO) in 2018, making it reimbursable when performed in hospital outpatient departments (HOPDs).
Two years later, CMS added TKA to the ASC Covered Procedures List (ASC-CPL). It also moved total hip arthroplasty (THA) from the IPO list to the ASC-CPL list starting in 2021, making both procedures eligible for Medicare reimbursement.
These changes signaled a federal regulatory belief that TJA procedures can be performed safely on Medicare beneficiaries, who are older and at times less healthy than the general population. This belief is backed by research, including a study published in 2019 in the Journal of Arthroplasty that focused on THA procedures.
In the study, two surgeons performed 3,063 THAs between 2013 and 2018, with 965 performed outpatient (335 in ASCs and 630 in HOPDs) and the remainder performed inpatient. No differences were found between the groups for 90-day complication rates, revision rates, all-cause reoperation rates, emergency department visits or readmission rates.
“THA can be safely performed in both ASC and HOP settings,” the study’s authors concluded. “Based on the populations studied, we identified no statistically significant differences in rates of complications between ASC and HOP groups.”
Reducing HAIs and SSIs
Performing TJA outpatient in an HOPD or ASC also greatly reduces the chance of patients contracting hospital acquired infections (HAIs). These occur in up to 4% of all hospital patients, while surgical site infections (SSIs) occur in up to 2.5% of TJAs performed in hospitals.
Up to 26,000 joint replacement patients face additional treatment, longer hospital stays and potential disabilities and lost wages each year due to SSIs, while up to 800 of these patients die from their infections.
A study performed by UnitedHealth Group noted that since many joint replacement patients no longer require inpatient hospital stays, performing these procedures outpatient in ASCs can greatly reduce these complications.
“Performing hip and knee replacements on an outpatient basis and discharging patients on the same day when strong protocols are in place does not increase the risk of complications or readmissions compared to patients who have the same surgeries and stay overnight,” stated the authors of the study.
The authors added: “ASCs can deliver a focused model for joint replacements and other high-volume surgeries by providing a consistent and controlled environment that avoids the challenges and inefficiencies of delivering many different surgical and medical services.”
The UnitedHealth Group study recommends assessing three main criteria to identify patients who can undergo these procedures most safely:
- The presence and severity of comorbidities.
- Social factors, including home environment and the presence of caregivers.
- Patient motivation.
“ASCs with established joint replacement programs are operating safe, scalable models that achieve high-quality results for knee and hip replacement surgeries,” stated the authors of the study. Their approach – which is built on specialization, repetition and scale – improves outcomes by increasing consistency. Key elements of the approach include the following:
- Care pathways specific to joint replacement patients. These help ensure each component of the surgical intervention is optimally defined, sequenced and executed.
- Physicians operating with teams consisting of their preferred surgical technicians and nurses.
- Operating rooms customized for surgeons and their teams.
According to the UnitedHealth Group study, if half of routine hip and knee replacements performed in hospitals on an inpatient basis were performed in ASCs instead, more than 500,000 surgery patients each year would avoid an overnight hospital stay. This would result in total savings of $3 billion per year: $2 billion in savings for privately insured individuals and employers and $1 billion in Medicare savings (for beneficiaries and the federal government).
Surgical Care Affiliates (SCA), a UnitedHealth Group company that operates more than 230 ASCs nationwide, demonstrates the results that can be achieved via outpatient TJA. At SCA centers that performed at least 25 joint replacements in 2019, 99.3% of patients completed an infection-free surgery and were discharged without requiring a hospital visit. Only 0.3% of patients developed an SSI and 0.4% required a hospital visit within 24 hours of discharge.
Growth Trends in Outpatient TJAs
During a recent podcast, outgoing Ambulatory Surgery Center Association (ASCA) President Michael Patterson, who is the CEO of Mississippi Valley Health in Davenport, Iowa, discussed these trends with current ASCA CEO William Prentice. Patterson is one of the early pioneers of performing total joint replacement surgeries in an ASC setting.
Prentice pointed out the continuous growth occurring in the number of TJAs that are being performed outpatient in ASCs and projections that this growth will accelerate even more.
“The trends are continuing to rise as predicted,” said Patterson. “In 2022, we saw a 37% increase and the prediction is that by 2026, we’re going to see a 51% increase in outpatient total joint replacement. I think this is going to continue well beyond the next several years.”
For example, Medicare is projected to spend almost $50 billion on total joint replacement by 2030 on up to three and a half million procedures, said Patterson. He pointed to the addition of total knee and total hip arthroplasty to the Medicare ASC-CPL as major drivers in these numbers.
The national average for patients undergoing TJA who acquire an infection is about 2.5%, said Patterson. “At Mississippi Valley Health, our average is 0.2%,” he said. “And the net promoter score for our total joint patient population is 99 out of 100. Physicians love working in the surgery center and patients love getting care here.”
A key to the center’s success is two full-time ortho nurse navigators who walk all total joint and spine patients through every step of their procedure preoperatively.
“These nurse navigators meet patients on the day of surgery and talk to them postoperatively to determine if there are any issues and how to rectify them,” said Patterson. “Or if something happens afterward, how do we correct it? This has worked really, really well for us.”
TSAs Not Yet Medicare Approved
While total knee and hip replacements have been added to the CMS ASC-CPL, total shoulder arthroplasty (TSA) procedures have not. Many surgeons and ASC operators believe that CMS should move quickly to approve TSA for Medicare reimbursement.
“We see a lot of shoulder replacements still going to the hospital, but we believe there’s an absolute place for them in the surgery center,” said Patterson during the ASCA podcast. “We do them for a lot of commercial patients and this is the next step in the evolution. We have a lot of surgeons who are looking forward to being able to do these surgeries in an ambulatory surgery setting.”
Research also points to the safety of performing TSA in ASCs. A study published in the National Library of Medicine in 2018 analyzed 61 TSA procedures: 40 were performed inpatient and 21 were performed outpatient at a freestanding ASC using a multimodal pain regimen without regional anesthesia.
All patients who had their TSA performed outpatient were discharged on the day of surgery, and no complications related to the outpatient protocol were observed. In addition, there were no major complications, readmissions, revision surgeries or deaths in the outpatient cohort.
The rate of 90-day complications was nearly twice as high for inpatient cohorts (17.5%) as it was for outpatient cohorts (9.5%) in the study. The percentage of patients who visited an emergency department or urgent care within 90 days of the surgery was almost the same: 5.0% for inpatient cohorts and 4.8% for outpatient cohorts.
“Outpatient shoulder arthroplasty can be performed safely and predictably in select patients at an ASC using a multimodal pain regimen without regional nerve block,” concluded the study’s authors.
ASC TJA Success Stories
Beth Russell, MSN, RN, CASC, is the executive director of the Knoxville Orthopaedic Surgery Center in Knoxville, Tennessee. In 2022, 70 total shoulder replacements were performed at the facility, which constituted a small percentage of the 1,300 total joint replacements they performed last year.
“We have been very successful with TSAs and experienced excellent patient outcomes and high patient satisfaction rates,” says Russell. “The advancements made in multimodal pain control have been a big contributing factor in the success rates.”
Russell points out that many TSA patients her center’s physicians are operating on at local hospitals are going home the same day. “So, I think Medicare should consider moving TSAs to the outpatient setting,” she says. “The only reason I can think of that they haven’t is because this surgery is routinely performed on an older population that has historically brought with it more comorbidities.”
However, Russell is concerned that the Medicare reimbursement rate might not cover the cost of the procedures. “Implants for TSAs are very expensive,” she says.
Rob Gagnon is the chief executive of the Yellowstone Surgery Center in Billings, Montana. In 2022, 126 total shoulder replacements were performed at the facility, and 50 had been performed through the first quarter of 2023.
“We have seen great results when completing total shoulder surgery as an outpatient procedure,” says Gagnon. “There have been zero reported infections or complications and patients appreciate the outpatient setting for this procedure. It’s more convenient than at a large hospital, the care is more personalized, the atmosphere is friendlier and it’s easier to park.”
Gagnon cites a number of other benefits of outpatient TSA including faster recovery times, quicker return to normal activities, a much lower infection rate and being able to recover more comfortably at home.
“Our experience has been that patients thrive with this procedure in the outpatient setting,” says Gagnon. “The majority of patients we have provided this service to have been discharged only a few hours following surgery. This presents a remarkable cost saving opportunity for Medicare, so we’re not sure why Medicare hasn’t approved total shoulders in the outpatient setting.
“As a facility, we would support and highly recommend that total shoulder surgeries become approved on the ASC allowable list,” adds Gagnon. “We would not proceed with this procedure in the outpatient setting if there was any concern regarding patient safety or an implication of poor outcomes.”
ASCA Supports TSAs in ASCs
Prentice also feels strongly that TSAs should be added to the CMS ASC-CPL. “Thanks to advances in surgical techniques, anesthesia and pain management, ASCs have been performing total shoulder arthroplasties for non-Medicare patients for years,” he says.
“Numerous studies, including some involving Medicare-age patients, confirm both top-quality outcomes and high levels of patient satisfaction with TSAs performed in ASCs,” Prentice adds. “It’s time for Medicare to allow beneficiaries access to these procedures in surgery centers.”
Prentice points to barriers that are preventing more TJAs from being performed in ASCs, including the way Medicare reimburses devices and implants in ASCs.
“We have seen some progress in recent years for procedures that involve implants, but the costs of the implants must be fully covered or surgery centers will not be able to provide these procedures for Medicare beneficiaries,” says Prentice.
Another barrier is a not having a copay cap for Medicare Part B services for ASCs like the one that exists in HOPDs. The absence of this cap in the surgery center setting means patients pay lower copays for certain high-cost procedures when they are performed in hospitals, but Medicare pays significantly more.
This perversely encourages patients to choose the higher cost hospital setting, limits Medicare patients’ access to care in surgery centers, and ultimately increases costs to Medicare, its beneficiaries and taxpayers.
According to Prentice, the Outpatient Surgery Quality and Access Act of 2023 contains a provision that would eliminate this penalty.
“Congress should enact this provision of the bill – and the entire legislation, for that matter – to cut Medicare’s costs and ensure that Medicare patients have access to the many benefits surgery centers provide,” says Prentice.
For more information on the other provisions of this legislation, visit www.ascassociation.org/outpatient-surgery-quality-and-access-act.
