Outpatient joint replacement vs. ambulatory joint replacement?

Over the past 5 years, there has been a lot of discussion about "outpatient joint replacement."

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


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