Outpatient joint replacement vs. ambulatory joint replacement?

*DISCLAIMER: THE FOLLOW IS AN ARTICLE WRITTEN BY DR. STEVE LUCEY MD ON the outpatient surgery website. CLICK HERE TO BE REDIRECTED TO THIS ARTICLE ON THEIR WEBSITE.

With all the emphasis on value-based care, joint replacement has been targeted as an opportunity to reduce cost by movement from inpatient to outpatient admissions, resulting in a reduction in skilled nursing admissions and decreased home health utilization. The BPCI program led the way and continues to be successful in some markets. Many research articles have been published in peer-reviewed journals citing the cost savings and the improvement in outcomes. However, there still seems to be some hesitancy for migration to the ambulatory surgery center. In 2016, the SG2 forecast was for 32% of joint replacements to be done in the ASC by 2022. We haven’t even hit half of that. Why?

REASON #1: Site of Serve Shift. It is one thing to do an “outpatient joint” in the inpatient setting where it is coded as HOPD (hospital outpatient department). You still have the safety net of the big hospital; you still have your same staff, same rooms and it is, in fact, cheaper with a reduced facility fee/DRG payment. However, to move it to the most cost-effective venue of the outpatient surgery center it requires an entirely new care paradigm, from pre-admission testing to patient education, staffing, sterile processing, care management, etc. So, the site of service shift is not easy and, therefore, slow to progress and hit the SG2 forecast.

REASON #2: Alignment. To shift the site of service to the ASC, there must be alignment with the surgeon, the payer and the ASC. Since it is a heavy lift to create programs and protocols around a purely outpatient joint without an inpatient backdrop, systems have struggled to figure it out and shift the volume to the ASC in large numbers. It is simply easier to keep doing things the way you always have unless there is some incentive to change. Commercial bundles and increased facility fees in physician-owned ASCs have seen excellent success in certain markets.

REASON #3: Risk Assessment. The pandemic certainly gave outpatient joints a push and many surgeons were forced to ask a different question as their OR’s were closed. We used to ask "Who can I do at the ASC?" However, now we ask "Who CAN'T we do at the ASC?" To help answer this question, we developed an evidence-based risk assessment tool, which is built into our software program called ValereCARE, that we put all of our patients through. They are assessed as type 1(healthy and safe to be done in the ASC), type 2 (comorbid conditions needing clearances but can be done in the ASC if cleared) and type 3 (too many co-morbid conditions and should be done in the hospital setting). We are embarking on a research study to validate this tool and hope for others to be able to utilize it in their ASC’s.

We hope the industry progresses more and more towards ambulatory joint replacement as surgeons and their staff get comfortable with this new value-based paradigm of care. It requires alignment of payers, ASC executives and other industry leaders such as implant companies. We will be gathering these various groups for the third time at our Valere Summit on Ambulatory Joint Replacement on September 22-23 and all are welcome to come and take part in this interactive value-based discussion. Registration and an agenda can be found at www.valerebundledsolutions.com/summit.