Outpatient cases of total joint replacement (TJR), a procedure so complex and potentially risky that it once required patients to be confined to hospitals for days, are on the rise in the US, thanks to advances in medical technology and protocols. Though not commonly practiced and vastly dwarfed by the number of inpatient procedures, outpatient TJR has drawn attention for its potential to reduce costs with comparable patient outcomes. Currently, however, clinical and regulatory obstacles stand in the way of its widespread adoption.
Outpatient TJR has several advantages over inpatient treatment. Generally, treating patients outside of the hospital setting dramatically reduces associated costs and TJR is no exception. New minimally invasive surgical techniques and more effective pain management tools have hastened recovery time and limited the need for continuous medical supervision. In some cases, the outpatient procedure costs nearly 50 percent less than inpatient. In addition, outpatient TJR naturally offers more convenience for patients who would otherwise undergo a lengthy inpatient stay. Most importantly, outcomes are roughly the same for patients treated on an outpatient basis, with comparable rates of readmissions and complications, according to a 2014 study.
Not everyone is an ideal candidate for outpatient TJR. Patients must be in otherwise good health with no history of conditions such as cardiac arrhythmia, liver disease, or pulmonary disease. The process is also generally restricted to those under 70 with BMIs less than 35 or 40. And while patients go home the same day, they still require the typical caregiver oversight and physical therapy regimen they would receive in a hospital, which may not always be possible at the home residence. Patient selection is critical and a major reason why outpatient TJR can claim similarly favorable outcomes to inpatient treatment.
Ironically, given that TJR cost Medicare roughly $7 billion in hospitalization costs in 2014, CMS regulations also discourage outpatient TJR. Medicare currently does not cover the procedure on an outpatient basis due to safety concerns, though CMS previously explored allowing outpatient knee replacement in a proposed rule in 2012. As a result, most hospitals and surgical providers opt not to invest in the training and procedures outpatient TJR requires. That could change in the future as value-based reimbursement provides a greater share of hospital revenues. Many surgery centers that offer outpatient TJR include the service as part of a bundled-payment agreement with insurers. CMS has also shown recent interest in improving total joint replacement quality and efficiency, launching a mandatory risk-sharing bundled-payment program at roughly 800 hospitals called the Comprehensive Care for Joint Replacement model.
Despite the challenges, it appears likely that outpatient TJR will grow more popular and available in the coming years. A 2015 presentation from healthcare consulting firm Marcia Friesen & Associates estimates that the annual number of outpatient TJR surgeries will reach 169,000 in 2018. While it requires a specific type of patient and a very well-organized and capable clinical team, outpatient TJR’s potential financial savings and patient benefits will be hard for hospitals to ignore.
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