OR Manager - December 2019 - 27

AMBULATORY
SURGERY CENTERS
look at the home if staff have concerns.
Does their house have stairs, and will
they need to go upstairs after they return
home from surgery? Will they have someone
to help them? What's their support
system at home? A very weak support
system could knock them out as candidates
for outpatient TJR surgery.
What are the financial/payer
considerations?
The only TJR procedure Medicare previously
paid for was approximately $7,600
for a uni-compartmental knee replacement.
As of January 2020, Medicare will
add total knee replacement to their list,
reimbursing $8,639.97 for that.
Other procedures such as total hip
and total shoulder are not yet on the
Medicare list, although total hips will be
removed from the inpatient-only list in
2020. Private payers will usually cover
total hips and shoulders, but you will
likely need to negotiate a carveout. The
range of reimbursement for these procedures
is $7,500 and more depending
on where you live, plus implants. If your
reimbursement is lower than what Medicare
pays, you should renegotiate your
rate with the payer.
Will Medicare's recent coverage
of total knees encourage more
ASCs to offer TJR?
It will. The same thing happened when
Medicare added lot of spine procedures
several years ago. However, some
ASCs, eager to do spine, found out that
they were spending more money on
supplies and implants than they were
getting paid by Medicare. That's why
this is a big risk, if you don't know all
the upfront costs.
What costs are and are not
covered with TJR?
If you keep people overnight, try and
negotiate a higher rate. It can be costly
to keep someone overnight. Make sure
your reimbursement is enough to cover
that. If your profit margin is slim, it may
not work. Find out what payers cover for
implants-a very expensive part of TJR.
Medicare covers implants at hospitals,
but not at ASCs.
Physicians who previously worked in
the inpatient setting may not be cognizant
of the cost of implants-these are
not always a pass-through cost like they
are in hospitals.
This is especially true with Medicare.
You need to know what kind of implants
your surgeons will be using. Know your
total case costs and see if Medicare
will work for you.
Is there any advice for how to
get surgeons to standardize
implants?
I would start with gathering all of the
costs of the current implants used and
organize them into a spreadsheet by
physician who uses them. You can
present this information at a meeting
with all of the physicians and let their
competitive natures take over. You also
need to remind them of the payers that
bundle implants as many no longer pay
cost plus for implants.
What are some of the big-ticket
equipment costs?
Facilities aren't paid extra to use robotic
technology. It's important to analyze
what the average per-case reimbursement
is in order to figure out how many
more cases you would need to pay for
that robot, based on your payer mix.
You can lease for robotics, but how
many more cases a month would you
need to pay for that lease? Other considerations:
The disposable hoods worn
by physicians to avoid infection are expensive.
Hip replacement requires a
Hana table, which can cost more than
$100,000. TJR requires large power
drills. Two sets of those drills can cost
more than $100,000.
What worries patients the most?
Most patients are very worried about
pain, so you want to set expectations
about pain management. Teach them
what to expect and how their pain will
be managed.
Another concern is when they can return
to normal activities-something the
physician should address with them.
Some patients worry about going home
the same day. Staff at the ASC need
to allay fears about recovering at home
and why it's preferred to staying overnight.
The infection rate in ASCs is less
than in hospitals because patients go
home and aren't exposed to sick patients
in the hospital. That and sleeping
in their own bed are big selling points.
What is the best way to educate
patients?
One of the most successful things is to
have patients take a class in advance
of surgery. They learn what the procedure
involves, what they can expect,
and what they need to do. The more
they understand, the better their recovery.
They meet with anesthesia providers
to discuss the plan for anesthesia,
and they see the facility and understand
what's going to happen.
The education is typically mandatory.
It may include family members or
caregivers as well, and if you have the
space to include them, it is a wise idea.
The facility should reinforce this visit
with a phone call. Patients need to understand
what will happen after surgery.
When they're in the immediate recovery
room, they won't remember what the
plan is for care at home, whether they'll
need outpatient physical
therapy, or
whether they'll need someone to come
to the house. The more education you
do ahead of time, the happier the patient
will be. ✥
Jennifer Lubell is a healthcare writer
based in Rockville, Maryland.
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OR Manager | December 2019
27
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OR Manager - December 2019

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