Financial and care consequences of CMS' outpatient joint replacement proposal feared

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A recent proposal from the Centers for Medicare & Medicaid Services to allow coverage for outpatient joint replacements could lead to financial losses and questionable care outcomes, hospital officials say.

Representatives for hospitals told Modern Healthcare in a report published Saturday that CMS' proposal, announced last month, doesn't have enough research to back it up.

“We haven't seen a lot of data that would show performing those procedures in ambulatory centers with no inpatient stay would result in better outcomes," Sabra Rosener, vice president of government affairs for UnityPoint Health, told Modern Healthcare.

Skilled nursing providers also stand to take a hit if the proposal passes, since medical advances in ambulatory surgery centers and other outpatient settings are allowing patients to bypass their typical post-acute stay and recover at home. Very few patients who undergo surgery in an outpatient center require skilled nursing or rehabilitation, surgeons explained to Modern Healthcare.

Hospitals also fear that the move would lead to more operations being covered in outpatient settings. CMS is already accepting public input on allowing hip replacements to be covered in outpatient centers, as well as knee replacements.

“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."

The future of bundled payments is also called into question by the proposal, since sicker, more high-cost patients will likely stay with hospital care while healthier beneficiaries move to outpatient settings.

"You'd be moving the easiest cases out of inpatient, and then your average expenses will look a lot higher," said Joanna Hiatt Kim, vice president for payment policy at the American Hospital Association. “CMS needs to take action to make sure hospitals aren't penalized. We're troubled they didn't saying anything about that."