More surprisingly, the CMS also sought comments on whether Medicare should pay for total and partial hip replacements in both hospital outpatient departments and ambulatory surgery centers.
Experts said providers should prepare for the shift as soon as Jan. 1, 2018, for total knees. "It's pretty clear that regardless of provider sentiment, CMS is looking to move ahead with this," said Eric Fontana, managing director of research for the Advisory Board Co. "For many providers this is going to be a shot across the bow. It will cause them to plan ahead, especially with the knowledge that if total knee passes, total hip will follow closely."
That would be a jolt for hospital managers, because most U.S. patients who receive total hip or knee replacements, even those under 65 covered by private insurance, still are operated on in an inpatient surgical unit. They often spend several days in a hospital bed, then move to a skilled-nursing or rehabilitation facility or receive home healthcare.
But that's changing at an accelerating pace, say orthopedic surgeons, hospital and ambulatory surgery center administrators, and outside analysts.
With advances in surgical technique, anesthesia and pain control, a growing number of surgeons are moving more of their total joint replacement procedures out of the hospital, performing them in ambulatory surgery centers. Some are sending their patients home within a few hours, while others have their patients recover overnight in the surgery center or hospital during 23-hour stays. These surgeons say very few of their patients require skilled nursing, rehab or home healthcare.
More than 200 ambulatory surgery centers around the country are performing outpatient joint replacements, according to Steve Miller, COO of the Ambulatory Surgery Center Association, which supports the CMS' proposed rule change. That's up from about 25 centers doing these procedures three years ago.
A relatively small number of Medicare patients enrolled in Medicare Advantage plans already are having their joint replacement operations done in ambulatory centers, Miller said.
"I could do maybe 20% of my Medicare patients on an outpatient basis, as long as they have the support and structure at home to help them recover," said Dr. Matthew Weresh, a partner in the 30-doctor Des Moines (Iowa) Orthopaedic Surgeons group. He and his colleagues are preparing to start doing joint replacements in an ambulatory surgery center later this year. "It's a great move by Medicare."
An estimated 25% to 50% of total joint replacements could be done on an outpatient basis, based on patients' health, weight and home support, according to the ASCA's Miller. "There's more and more comfort among surgeons who are coming out of residencies where they trained to do surgeries on an outpatient basis," he said. "The volumes are doubling year over year."