Medicare’s 2018 policy change supporting outpatient total knee replacement (TKR) may have led to more surgeries and higher costs, while unintentionally limiting access, a new study has found. Outcomes, meanwhile, have remained unchanged.
The decision to remove TKR from the inpatient-only list was made after data showed these surgeries would be feasible to perform in the outpatient setting. Investigators from the University of Rochester Medical Center in Rochester, NY, examined subsequent data for over 37,000 Medicare fee-for-service procedures.
Although outpatient TKR utilization has been increasing since the policy was implemented, evidence of disparities have also emerged, study lead Derek Schloemann, MD, MPHS, reported. “Older, Black and female patients, patients with more medically complex conditions and patients treated in safety-net hospitals were less likely to be selected for outpatient TKR,” he and his colleagues wrote.
Although the reason for the latter finding is unclear, it raises the question of whether the policy change has led to reduced access to outpatient TKR for these patients, and whether there may be a disincentive to care for them, the authors added.
Reasons for the disparities may include inadequate surgical risk assessments, treatment by surgeons with less experience in outpatient TKR and treatment at facilities not equipped to support the procedure, Schloemann theorized.
Higher costs, same outcomes
At the same time, the cost of the surgeries has also risen — by $770 per encounter — yet there has been no difference in surgical outcomes, including discharge to post-acute care, hospital readmissions and emergency room visits, when compared to outpatient total hip replacements.
“A continual monitoring of the use and outcomes of outpatient TKRs is essential for realizing the policy’s intended goals and avoiding unintended worsening of disparities,” they concluded.
Full findings were published in JAMA Network Open.
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