Outpatient total joint replacements are gaining steam; physicians across the country are preforming outpatient total joints in hospitals as well as ASCs. Medicare is also considering removing total joint replacements from the inpatient only list.
Barry Waldman, MD, director of the Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopedics in Baltimore, and Derek Johnson, MD, an orthopedic surgeon and secretary at Denver-Vail Orthopedics discuss outpatient total joint replacements in their practices and where the procedure is headed in the future.
Question: Why do you feel Medicare should or shouldn't allow total knee replacements in the outpatient ASC setting?
Dr. Derek Johnson: I feel it is in the best interest for Medicare to allow joint replacement to occur in the outpatient setting due to the substantial cost savings for the system. An ambulatory surgery center can likely provide joint replacement in the healthy Medicare population at a cost 25 percent to 40 percent lower than traditional hospital costs. Ambulatory surgery centers are often found to have lower infection rates and complication rates compared to inpatient hospitals as they are not commonly caring for patients with infections and complex medical problems.
Dr. Barry Waldman: Outpatient knee replacement is an exciting development as it is more pleasant and convenient for a select group of patients. It also can be dramatically less expensive, as much as 40 percent cheaper, with no decrease in safety. I think that Medicare has duty to both its enrollees and to the nation's taxpayers to approve this for some total knee cases.
Q: What are the key concepts for total joint surgeons to consider when deciding whether to expand their practice to include outpatient total joints?
BW: Any physician considering outpatient knee replacement should have extensive experience with both knee replacement and the postoperative care involved. The highest volume surgeons are the ones who will feel most comfortable and take the lead in this area.
DJ: Surgeon volume and current quality must first be considered. I also feel it is necessary to be comfortable performing short-stay and same day discharge for joint replacement patients in a hospital setting prior to transitioning to an ambulatory surgery center. I performed over 150 same day discharges at an inpatient hospital and had nearly 90 percent of my patients discharging on the day of surgery or post-op day one prior to transitioning joint replacement to ambulatory surgery centers.
Q: How could Medicare removing total joint replacements off of the inpatient only list affect the quality and cost of care?
DJ: Please see cost comments and comments regarding infection above. In addition, ASCs can offer a better patient experience by decreasing the time spent at the facility. My same day discharge patients at the hospital often spend 10 to 12 hours at each facility due to inefficiencies encountered in the inpatient setting and government required paperwork and processes. In the ASC, most patients spend less than six hours at the facility.
BW: As I mentioned earlier, an inpatient total knee replacement can cost $30,000 or more, sometimes twice as much. Our center can do a total knee replacement for about $23,000. There are certainly a large number of patients with other medical problems that are not appropriate for outpatient surgery but I believe that up to 30 percent of patients could eventually have their surgery in an ASC saving millions of dollars for Medicare. Our center has also been able to save additional money using a ConforMIS patient matched knee as it dramatically lowers the number of instruments we need and the cost to process them. The preliminary data shows no difference in complication rates if patients are carefully selected.
Q: What are the most important patient selection factors for outpatient total joints?
BW: The most important criteria are relative lack of serious medical problems such as diabetes, heart disease and obesity. Patient motivation and a good support system at home are also crucial.
DJ: Overall health is the most important factor. I would recommend against diabetic patients or patients with multiple medical comorbidities. Also, BMI is a very good predictor of same-day discharge. Most patients should have a BMI under 30. Select patients with a BMI between 30 and 35 may be candidates, but I would avoid any patient with a BMI greater than 35. Age is also a predictor. Patients 65-70 are much more likely to discharge the day of surgery than patients greater than 80. Although, I do have a handful of patients every year 80-plus that are able to discharge the day of surgery.
Q: What percentage of your Medicare total joint patients could be taken outpatient if it were allowed?
BW: Again, up to 30 percent of Medicare patients would eventually benefit from outpatient total knee replacement, especially in centers that have a 23-hour stay capability.
DJ: At this point, approximately 25 percent of my Medicare age patients are discharging the day of surgery. However, if you look at my patients 65 to 70 [years old], approximately 40 percent are discharging the day of surgery. This however, is done in the hospital. I think those numbers could increase if we were able to perform the surgeries in the ASC setting. I have seen this in my unicompartmental arthroplasty patients. Ninety percent of my Medicare unicompartmental arthroplasty patients performed in ASCs discharge the day of surgery without a 23-hour stay, while only 50 percent of my unicompartmental arthroplasty patients performed in the hospital discharge same day.