'CMS needs to revisit' 2022 outpatient proposal, Twin Cities Orthopedics president says

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CMS has proposed several changes for 2022, with plans to halt the elimination of the inpatient-only list and return 298 musculoskeletal services back to the list being the most significant changes that would affect orthopedic care.

Owen O'Neill, MD, president of the board of directors at Golden Valley, Minn.-based Twin Cities Orthopedics, shared his thoughts with Becker's on the proposed changes and outlined why he believes CMS should revisit this proposal with more input from all orthopedic stakeholders.

Question: What do you think about CMS' proposal to return 298 musculoskeletal procedures back to the inpatient-only list in 2022?

Dr. Owen O'Neill: I saw that CMS had cited patient safety, but I think the biggest issue and what we're really talking about here is site of service — where do patients get their care? Ultimately, I don't think you can be sweeping about which patient gets care in which setting. It's less about the particular procedure than it is about the particular patient. Some patients, based on their medical situation, are good candidates for an outpatient site of service rather than an inpatient one. Other patients are really best served as an inpatient. 

Making blanket statements that this procedure must be done inpatient, or this procedure must be done outpatient, is not the right approach. The right approach is that the physician, who takes care of the patient and has an informed, shared decision-making process with that patient, decides where the best site of service is for many of these procedures. So, CMS saying these procedures must be taken off the inpatient-only list and can only be done outpatient versus being only on the inpatient-only list, I just don't think it individualizes patient care. 

Q: How would this affect your practice and the wider orthopedic field in the coming years?

OON: We've done over 7,000 outpatient total joints, so we have vast experience with these types of procedures. When CMS made the move to take them off the inpatient-only list, we started making plans to ramp up those cases in our ASCs. We've gone fairly slowly with that because we want to make sure the site of service is right for each individual patient. 

It may make more of an impact in terms of planning at our ASCs in today's world. Our ASCs continue to be exceedingly busy, and to bring a lot of these patients into the ASC would certainly require more growth on our end. We may need to modify some of those growth plans based upon this new CMS proposal. In terms of site of service, we still believe finding the best site for the right patient is of utmost importance, and that many of these procedures can absolutely be done on an outpatient basis.

Most of our total joint cases are outpatient candidates, but, again, it's more about the patient and their medical situation and less about the procedure. Shoulder replacements, ankle replacements, hip and knee replacements, as well as many spinal decompressions and fusions, can all safely be done on an outpatient basis. It is difficult to have a one-rule-fits-all. A patient's medical situation dictates where they need to be taken care of. For example, the same procedure that can safely be done on patient X should be done on an inpatient basis for patient Y. That might be because patient Y has diabetes, obesity, kidney disease or heart disease. It's about their medical needs more than the procedure itself. 

Q: What do you think prompted this U-turn less than one year after CMS removed these procedures from the inpatient-only list?

OON: I love transparency in our world. We take CMS at their word when they cite patient safety, and we'd like to see that data. At the end of the day, we're all about taking care of patients.  If there's a certain population that shouldn't be taken care of on an outpatient basis due to a patient safety issue, we want to see what that is. Our hope is that CMS will disclose that information because we'd like to be part of that conversation. For every physician, it's our oath to first do no harm. Patient safety is paramount to us, but we want to understand what those issues are and how we can modify them in such a way that those procedures can be done safely in the outpatient environment. 

You must remember that in the outpatient setting there are many procedures that have less complications than being in a hospital. We're now seeing another spike in COVID-19 cases, and hospitals may not be the safest place for patients to get their care. If certain procedures can be safely done at a particular site, I think it's important that we continue to offer that.

Q: What one change would you like CMS to implement for the benefit of orthopedic care?

OON: I think CMS already made the best change they could have for orthopedic care, but now they're going back on it. That is the move to an outpatient setting at the discretion of the treating physician. The greatest thing they could do is not make a blanket statement that says a certain procedure can only be done inpatient. 

Moving a procedure off of the inpatient-only list allows procedures to be done at a place where it's safe and specific to that patient. This is a really important topic, which I think CMS needs to revisit with the stakeholders, who include orthopedic surgeons, independent orthopedic surgeons, groups of orthopedic surgeons, our academy and other stakeholders  —  not just hospital systems.

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