The Unintended Impact of the Removal of Total Knee Arthroplasty From the Center for Medicare and Medicaid Services Inpatient-Only List.

BACKGROUND: Total knee arthroplasty (TKA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) list starting January 1, 2018. Many hospitals responded by instructing surgeons to schedule all TKAs as outpatient procedures, and some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases. This activity and ensuing confusion has caused considerable unintended disruption for surgeons, hospitals, and patients. The purpose of this study was to gauge the impact on providers and patients. METHODS: Active members of the American Association of Hip and Knee Surgeons were sent a 9-question survey asking if the surgeon's hospital was treating all patients undergoing TKA as outpatients and if Medicare Advantage administrators and commercial payers were treating all or most the same. Questions also inquired about the impact on surgeon practices and their patients. RESULTS: Seven hundred thirty members (26%) responded; of which, 59.5% reported that their hospitals have instructed them that all Medicare TKAs should be scheduled as outpatient procedures; 40.5% have been asked to use proscribed documentation to justify that change; 30.4% reported that their patients have incurred added personal cost secondary to their surgical procedure being billed as an outpatient procedure; and 76.1% report that this issue has become an administrative burden. CONCLUSION: The CMS clearly stated its expectation in the 2018 Outpatient Prospective Payment System Final Rule that the great majority of Medicare fee-for-service TKA patients would continue to be treated as inpatients. Nonetheless, many hospitals have decided to schedule all TKA cases as outpatients due to the 2-midnight rule despite a moratorium on recovery audits. It is the position of the American Association of Hip and Knee Surgeons that the CMS needs to provide more specific expectations concerning the needed language justifying admission or exempt TKA from the 2-midnight rule to mitigate the unintended confusion demonstrated by hospitals and some payers that has resulted from the removal of TKA from the Inpatient-Only list.

Can Total Knee Arthroplasty Be Performed Safely as an Outpatient in the Medicare Population?

BACKGROUND: The Centers for Medicare and Medicaid Services has solicited public comments for the 2017 Proposed Rule to consider removing total knee arthroplasty (TKA) from the Inpatient Only List. The purpose of this study is to compare the complication rates between outpatient (same-day discharge), short-stay (discharge within 1 day), and inpatient TKA and to identify the ideal candidates for a short-stay or outpatient procedure. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database for patients over age 65 years who underwent TKA from 2014 to 2015. Demographics, comorbidities, 30-day complications, and readmission rates were compared between patients after outpatient, short-stay, and inpatient procedures. A multivariate regression analysis was then performed to identify at-risk patients who should not be candidates for outpatient or short-stay TKA. RESULTS: Of the 49,136 Medicare-aged TKA patients, 365 (0.7%) were outpatient, 3033 (6%) were short-stay and 45,738 (93%) were inpatient. Short-stay patients had a lower complication rate than both the outpatient and inpatient groups (2% vs. 8% vs. 8%, P < .001). Independent risk factors (all P < .05) for experiencing a complication or requiring an inpatient stay include female gender (odds ratio [OR] 1.655), general anesthesia (OR 1.282), diabetes mellitus (OR 1.171), chronic obstructive pulmonary disease (OR 1.579, P < .001), hypertension (OR 1.144), kidney disease (OR 1.425), American Society of Anesthesiologists Score 4 (OR 1.748), body mass index >35 kg/m2 (OR 1.265), and age >75 years (OR 1.429). CONCLUSION: TKA can be performed safely as an outpatient in a subset of healthy Medicare patients with a complication rate similar to an inpatient stay. A 23-hour stay, however, may be the "sweet spot" that minimizes complications in this population.

Should Medicare Remove Total Knee Arthroplasty From Its Inpatient Only List? A Total Knee Arthroplasty Is Not a Partial Knee Arthroplasty.

BACKGROUND: The Centers for Medicare and Medicaid Services have solicited comments to consider removing total knee arthroplasty (TKA) from the Inpatient Only list, as it has done for unicompartmental knee arthroplasty (UKA). The purpose of this study is to determine whether Medicare-aged patients undergoing TKA had comparable outcomes to those undergoing UKA. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients aged 65 years or older who underwent elective TKA or UKA from 2014 and 2015. Demographic variables, comorbidities, length of stay (LOS), 30-day complication, and readmission rates were compared between UKA and TKA patients. A multivariate regression analysis was then performed to identify independent risk factors for complications and hospital LOS greater than 1 day. RESULTS: Of the 50,487 patients in the study, there were 49,136 (97%) TKA patients and 1351 UKA patients (3%). Medicare-aged TKA patients had a longer mean LOS (2.97 vs 1.57 days, P < .001), had a higher complication rate (9% vs 3%, P < .001), and were more likely to be discharged to a rehabilitation facility (31% vs 9%, P < .001) than Medicare-aged UKA patients. When controlling for other variables, TKA patients were more likely to experience a complication (odds ratio, 2.562; P < .001) and require LOS >1 day (odds ratio, 14.679; P < .001) than UKA patients. CONCLUSION: TKA procedure in the Medicare population is an independent risk factor for increased complications and LOS compared to UKA. Policymakers should use caution extrapolating UKA data to TKA patients and recognize the inherent disparities between the 2 procedures.

Alternative Reimbursement Models: Bundled Payment and Beyond: AOA Critical Issues.

The Bundled Payments for Care Improvement (BPCI) initiative was begun in January 2013 by the U.S. Centers for Medicare & Medicaid Services (CMS) through its Innovation Center authority, which was created by the U.S. Patient Protection and Affordable Care Act (PPACA). The BPCI program seeks to improve health-care delivery and to ultimately reduce costs by allowing providers to enter into prenegotiated payment arrangements that include financial and performance accountability for a clinical episode in which a risk-and-reward calculus must be determined. BPCI is a contemporary 3-year experiment designed to test the applicability of episode-based payment models as a viable strategy to transform the CMS payment methodology while improving health outcomes. A summary of the 4 models being evaluated in the BPCI initiative is presented in addition to the awardee types and the number of awardees in each model. Data from one of the BPCI-designated pilot sites demonstrate that strategies do exist for successful implementation of an alternative payment model by keeping patients first while simultaneously improving coordination, alignment of care, and quality and reducing cost. Providers will need to embrace change and their areas of opportunity to gain a competitive advantage. Health-care providers, including orthopaedic surgeons, health-care professionals at post-acute care institutions, and product suppliers, all have a role in determining the strategies for success. Open dialogue between CMS and awardees should be encouraged to arrive at a solution that provides opportunity for gainsharing, as this program continues to gain traction and to evolve.

Discharge Disposition After Joint Replacement and the Potential for Cost Savings: Effect of Hospital Policies and Surgeons.

BACKGROUND: Up to 55% of total joint arthroplasty costs come from post-acute care, with large variability dependent on a patient's discharge location. At our institution, we identified a group of surgeons using a preoperative discharge planning protocol emphasizing the merits of home discharge. We hypothesized that using the protocol would increase patients' odds for discharge home. METHODS: Administrative data from 14,315 total hip and knee arthroplasties performed over a 3-year period were retrospectively analyzed to determine predictors of patient discharge location. Bayesian hierarchical logistic regression modeling was used to account for the complex multilevel structure within the data as we considered patient-, surgeon-, and hospital-level predictors. A simplified case-control data structure with logistic regression analysis was also used to better understand the impact of the preoperative discharge planning protocol. RESULTS: A variety of patient- and surgeon-level variables are predictive of patients being discharged home after total joint arthroplasty including a patient's length of stay, age, illness severity, and insurance, as well as surgeon's affiliation. In the case-control data, patients exposed to the rapid recovery protocol had 45% increased odds of being discharged home compared to patients not exposed to the protocol. CONCLUSIONS: Although patient factors are known to play a role in predicting postdischarge destination, this analysis describes additional surgeon- and hospital-level factors that predict discharge location. Exogenous factors based on how surgeons and hospital staff practice and interact with patients may impact the postdischarge decision-making process and provide a cost savings opportunity.

Bundled Payment in Total Joint Care: Survey of AAHKS Membership Attitudes and Experience with Alternative Payment Models.

The goal of alternative payment models (APMs), particularly bundling of payments in total joint arthroplasty (TJA), is to incentivize physicians, hospitals, and payers to deliver quality care at lower cost. To study the effect of APMs on the field of adult reconstruction, we conducted a survey of AAHKS members using an electronic questionnaire format. Of the respondents, 61% are planning to or participate in an APM. 45% of respondents feel that a bundled payment system will be the most effective model to improve quality and to reduce costs. Common concerns were disincentives to operate on high-risk patients (94%) and uncertainty about revenue sharing (79%). While many members feel that APMs may improve value in TJA, surgeons continue to have reservations about implementation.

Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force.

The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. Total hip and knee arthroplasties are viewed as ideal treatments to test the effectiveness of this payment model. Providers must learn the nuances of these modified care delivery concepts and evaluate whether their environment is conducive to success in this arena. This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.

In-home care following total knee replacement.

To meet the growing demand for total knee replacement (TKR) procedures, health care systems are obligated to design care paths that foster more rational use of resources, including home-based postacute care. Early discharge to home, with home-based rehabilitation and physical therapy, has been associated with reduced cost, improved clinical outcomes, and increased patient satisfaction. The goals of a home-based clinical care path for TKR include patient and family engagement, shared decision-making, and flexibility regarding changes in plans to accommodate changing needs.

A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value.

Members of a consortium of leading US health care systems, known as the High Value Healthcare Collaborative, used administrative data to examine differences in their delivery of primary total knee replacement. The goal was to identify opportunities to improve health care value by increasing the quality and reducing the cost of that procedure. The study showed substantial variations across the participating health care organizations in surgery times, hospital lengths-of-stay, discharge dispositions, and in-hospital complication rates. The study also revealed that higher surgeon caseloads were associated with shorter lengths-of-stay and operating time, as well as fewer in-hospital complications. These findings led the consortium to test more coordinated management for medically complex patients, more use of dedicated teams, and a process to improve the management of patients' expectations. These innovations are now being tried by the consortium's members to evaluate whether they increase health care value.