The Case for Out-patient Total Knee Arthroplasty

And Compelling Reasons Why 

In 2000 the Centers for Medicare & Medicaid Services (CMS) added Total Knee Arthroplasty (TKA) to the Medicare Inpatient Only (IPO) list in 2000. More than a decade later, in 2013, the CMS proposed that the procedure be removed from the IPO list in anticipation that some Medicare beneficiaries would be well served in an outpatient environment. There was considerable adverse public reaction to this proposed move so it was not finalized at that time.

Now, three years later, the CMS is once again considering removal of TKA from the IPO list and soliciting public comments on that proposal. Driving this effort are two prime factors:

1. In recent years there have been significant innovations in technology and procedures that point to TKA now may be performed with minimally invasive techniques and accelerated rehabilitation.

2. Successful experiences are being reported by surgeons performing outpatient TKA on an increasing number of non-Medicare, lower-risk patients.

Initial Responses to CMS Request for Comments

In August of this year, the Advisory Panel on Hospital Outpatient Payment unanimously recommended CMS remove total knee arthroplasty from its inpatient-only list.

The American Association of Hip and Knee Surgeons (AAHKS) is the foremost national specialty organization of 2,900 physicians with expertise in total joint arthroplasty procedures. In a detailed letter to CMS, AAHKS raises key considerations to address in determining the advisability of removing TKA from the inpatient-only list. A partial listing includes:

• Technological and procedural advancements
• Outpatient facilities equipped to provide TKA to Medicare patients
• Effect on existing CMS payment models
• Determining criteria for only healthiest patients to undergo outpatient TKA
• Criteria for safe discharge of a patient following TKA same for outpatient & inpatient.
• Post-surgery reporting

Experienced ASCs Weigh-In

Sohrab Gollogly, MD – Monterey Peninsula Surgery Center presented his ASC’s experiences in the Safety and Efficacy of Outpatient Arthroplasty at an August conference hosted by the Ambulatory Surgery Center Association.

His presentation includes the following successes and conclusions based on outpatient TKA procedures performed at Monterey Peninsula Surgery Center.

• Conclusion: CMA should consider TKA to be removed from the inpatient-only list.
• Professional Support: Over 100 peer-reviewed articles have been published.
• Medicare Patients Benefits: Appropriate Medicare patients will benefit from outpatient TKA by shorter hospital/ASC stays; good pain control; minimal risk of readmission or post-operative ER visits.
• Society & Taxpayer Benefits: Outpatient TKA procedures at 50% of the cost of inpatient; clinical outcomes and patient satisfaction scores equal to or better than the inpatient environment.

Nicholas Violante, OD – Excelsior Orthopaedics, LLP presented a comprehensive overview of the total joint replacement landscape – including observations regarding TKA. Some highlights:

• Volume, cost and demand for TJR growing exponentially
• TKA expected to grow by 673% by 2030
• What ASCs Need to Provide TKA
  • What’s needed to get started
  • Bundled payment reimbursement considerations
  • Equipment & planning
  • Patient selection criteria
• Conclusions – “A surgical experience like no other”.
  • Avoids hospital stay
  • Safe and effective
  • Better pain management
  • Lower risk of post-operative infection & complications
  • Direct access to physician
  • Accelerated rehabilitation
  • Decreases cost 30 – 40%

ASCs – Opportunity & Preparation

Given the foregoing, it is likely that outpatient TKA will become a reality. The anticipated positive financial impact for outpatient TKA facilities is significant. In 2015, Medicare covered about 450,000 inpatient TKA procedures with costs totaling more than $7 billion for hospitalization alone. And the average Medicare payment for surgery, hospitalization and recovery ranges from $16,000 to $33,000, depending on where the surgery is performed.

While there is no current projection of how many of these procedures could have been performed in an outpatient facility, clearly most any percentage will result in considerable savings … and significant increased capacity for ASCs that are prepared to provide compliant outpatient TKA services.

Technological advancements, procedural refinements, professional experiences with positive patient outcomes coupled with financial savings appears to be the ingredients for approval of the CMS proposal to expand TKA to properly equipped and staffed ASCs. ASCs interested in adding TKA to its surgical procedures should begin planning for the necessary facility, medical equipment and staff to qualify for participation.