The Initial Impact of COVID-19 on Total Hip and Knee Arthroplasty.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic caused a massive disruption in elective arthroplasty practice in the United States that to date has not been quantified. We sought to determine the impact of COVID-19 on arthroplasty volumes in the United States, how this varied across the country, and the resultant financial implications. METHODS: We conducted a retrospective analysis of Medicare fee-for-service beneficiaries undergoing primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 1st through March 31st, 2020 with 74,080 TKAs and 54,975 THAs identified. We calculated the percent drop in average daily cases from before and after March 18, 2020. We then examined variation across states in arthroplasty case volumes as it related to reported COVID-19 cases, the impact of COVID-19 on length of stay and percentage of patients discharged home. Finally, we calculated the revenue impact on hospitals and surgeons. RESULTS: There was a steep decline in TKA and THA volumes in mid-March of 94% and 92%, respectively. There was a significant variation for arthroplasty case volumes across states. We found minimal change in length of stay except for primary THAs with fracture going from 5 + days to 4 days. We saw an increasing trend in discharge to home with the greatest effect in primary THAs with fracture. The total daily hospital Medicare revenue for arthroplasty declined by 87% and surgeon revenue decreased by 85%. CONCLUSION: The beginning of the COVID-19 pandemic caused a significant decrease in arthroplasty volumes in the Medicare population with a resultant substantial revenue loss for hospitals and surgeons.

Economic Impact of Outpatient Medicare Total Knee Arthroplasty at a Tertiary Care Academic Medical Center.

BACKGROUND: In January 2018, the Center for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list. This impacted hospital reimbursement, Comprehensive Joint Replacement (CJR) bundle volumes, and bundle performance. We describe these impacts at an academic teaching hospital. METHODS: We reviewed CJR bundle data provided by CMS and internal databases to identify the shift in CJR TKA episode volume since January 2018, the impact on postacute care (PAC) utilization rates and readmissions, financial impact to the bundle, and impact on hospital reimbursement. We used data provided to CJR participants, internal hospital sources, and the Medicare Limited Data Set. RESULTS: Between 2017 and 2018, CJR TKA episodes decreased from 91 to 51 (44% reduction). Inpatient PAC utilization was significantly higher in 2018 (20% vs 8%). The 90-day readmission rates increased from 5.5% to 12.7%. Average variance to target dropped from 15% to 5%. Average CMS reimbursement for TKA at our institution in 2019 was $14,823 for inpatients and $9299 for outpatients. We experienced $930,463 in decreased reimbursement from January 2018 to September 2019 as a result of the shift from inpatient to outpatient. In addition, we expect $625,143 in decreased incentive payments as higher functioning and lower cost outpatient TKAs are excluded from CJR. CONCLUSION: Although CMS projected a minimal impact on CJR bundle participants, this has not been the case at our institution. We experienced reduced volumes, increased PAC utilization, and a substantial financial impact. We expect a similar outcome when CMS removes total hip arthroplasty from the inpatient-only list.

An Examination of the Adoption of Outpatient Total Knee Arthroplasty Since 2018.

BACKGROUND: The Centers for Medicare and Medicaid Services removed total knee arthroplasties (TKAs) from the inpatient-only (IPO) list on January 1, 2018, which meant that TKAs could be performed on a hospital outpatient basis. We examined the following: (1) the national rate of adoption of outpatient TKAs over time, (2) how adoption varied across hospitals, and (3) whether adoption of outpatient TKAs has positively or negatively impacted 90-day TKA readmission rates. METHODS: We used national patient-level Medicare Fee-for-Service Part A claims data (100% sample) from January 2017 through June 2019 to look at the quarterly trend in percent of TKAs performed as outpatient, and the distribution in this percentage across hospitals in the country. We ran a case-level regression to understand whether inpatient vs outpatient coding status relates to 90-day readmission rates. RESULTS: In 2017 prior to the removal of TKAs from the IPO list, 0.2% were performed as outpatient. In the first quarter (Q1 2018) after the rule change, 24.9% were performed as outpatient, and by the second quarter of 2019, 36.4% were performed as outpatient. These rates varied widely across hospitals from 0% (10th and 25th percentiles) to 78% (90th percentile) from January 2018 through March 2019. There was no difference in readmission rates for same-day discharges, but outpatient cases discharged after one or more nights in the hospital had statistically lower readmissions than inpatient cases. CONCLUSION: There was a rapid increase in the adoption of hospital outpatient TKAs following their removal from the Medicare IPO, which has resulted in lower readmission rates, and so adoption is likely to continue.