Total joint replacement is known for its success in the outpatient setting, but for one surgeon that has caused complications in some of his patients.
Anthony Melillo, MD, discussed those challenges with Becker’s.
Note: This response was lightly edited for clarity.
Question: How do you approach payer negotiations — particularly with commercial plans that may be resistant to the shift from inpatient to outpatient total joints?
Dr. Anthony Melillo. Bay Oaks Orthopaedics & Sports Medicine (Houston): The vast majority of the commercial payers classify total joint replacements as “outpatient.” The sole purpose is to save money for insurance companies since their contractual obligation is thousands of dollars less than inpatient status.
The issue is that the majority of patients that require total joint replacements are older & have more medical issues. Outpatient joint replacements are appropriate for a very narrow group of patients; they require more pre-operative counseling and more intensive immediate follow up by the hospital/surgeon. None of these are financially compensated by insurance companies.
I send all my patients to an internal medicine doctor for adequate pre-op medical optimization before all my total joint replacement surgeries. This prevents complications and usually documents a higher level of complexity that justified an “inpatient” classification.
There are times when an “outpatient” classification is upgraded to “inpatient” after the surgery if medical issues arise: blood loss; intractable pain; etc.
Finally, it is my professional opinion that only the insurance company benefits from “outpatient” joint replacements. The added burden falls on the patient; their family and the surgeon.
Would you want your family member to have a major surgery and you be responsible for the nursing/medical care for the initial 24-36 hours?
