The Latest News Regarding Total Joint Replacement Procedures
Articles, similar to the two noted in the links above, are beginning to appear in newspapers and journals across the country. Orthopedic surgeons are breaking new ground by performing total knee and total hip replacement procedures on an outpatient basis. These articles tell the stories of patients who have undergone total joint procedures on an outpatient basis and have returned to their prior activities within a few weeks. Previously, total joint procedures required an extended hospital stay followed by a long recovery and rehabilitation period lasting several months. With advances in surgical equipment, allowing the procedures to be performed with minimally invasive techniques, and improved perioperative and post-operative pain management protocols, select patients undergoing total joint replacements are able to walk within hours of the surgery and may be discharged the same day.
One of the reasons cited for this latest advance is economic in nature. It was noted in the Pittsburgh Press article that “there is a huge economic push to make this procedure less expensive and quicker”. On the heels of this advancement, CMS released a proposal for a new model of comprehensive care for joint replacements. [https://www.federalregister.gov/public-inspection] This proposal, as part of Department of Health’s recent efforts to transform the entire health care system, would focus on care transformation and payment reform for total joint replacement surgeries.
The purpose of this new model, as identified by CMS, is to improve the care experience for the growing number of Medicare beneficiaries undergoing total joint replacements by addressing the fragmentation identified across the whole episode of care, from pre-operative planning to post-operative rehabilitation. CMS has indicated that a patient’s health suffers when care providers do not see the big picture. This can result in post-surgical complications, hospital readmissions and inconsistent care and costs.
Under the proposed model, the hospital where the total joint procedure is performed would be responsible for the costs and quality of care for a ninety day period, starting on the day of surgery. This time frame would be denoted as an “episode of care”. The model would test bundled payment and quality measurement for the episode of care. Each year, during the five performance years of this model demonstration, CMS would set the cost of a total joint replacement at each participating hospital. All part A and Part B services, related to the total joint replacement, would be included in the bundled payment. All providers and suppliers would be paid as usual by Medicare for the episode services. At the end of the model demonstration year, the amount actually spent for the episode of care would be compared to the bundled cost set by CMS for that hospital. Depending on the outcome of the procedure from a care and cost perspective, hospitals would either earn a financial reward or be required to repay Medicare for a portion of the costs.
It is hoped that this potential payment would incentivize facilities to work with health care providers, home health care agencies and nursing facilities to ensure patients receive coordinated care, hopefully thereby reducing post-operative complications and hospital readmissions. The model would be instituted in 75 geographic regions of the nation and the majority of hospitals in these regions would be required to participate.
CMS has indicated that the cost of total joint procedures can vary significantly depending on geographic location. Medicare currently expends between $16,500 and $33,000 (inclusive of surgery, hospitalization and recovery) per total joint procedure. Additionally, the rates of post-operative complications can vary dramatically as well, with rates three times higher at some facilities.
With publication of this rule, CMS is requesting input from health care providers, beneficiaries and other stakeholders during the 60 day comment period. Comments can be submitted electronically through the CMS e-Regulation website found at https://www.federalregister.gov/articles/2015/07/14/2015-17190/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals