How total joints' outpatient migration could affect value-based pay

Eric Oliver -   Print  |

Medicare's decision to allow total joint replacements to be performed in the outpatient setting could affect value-based payment models in positive and negative ways, according to a piece in HealthAffairs. 

What you should know:

1. Total knee replacement was removed from the inpatient-only list in January 2018, and similar changes are expected for total hip replacement in 2020. Both moves are indicative of CMS' desire to transition low-acuity procedures to the outpatient space in cost-cutting measures. 

2. While the migration will cut costs, it will challenge payment models like Comprehensive Care for Joint Replacement and Bundled Payments for Care Improvement Advanced because of the fundamental shift in replacement. The author argues, "Site-of-service policy that shifts procedures toward outpatient or ASC settings would potentially siphon procedures out of these payment models, creating new challenges or exacerbating existing ones for program participants." 

3. In addition, the migration could create a scenario where less risky patients are channeled to bundled payment arrangements, leaving riskier patients excluded from bundles. 

4. The arrangement could also endanger how organizations are viewed in payment models. If one organization gets the lower-acuity cases, they'll likely have a higher success rate with fewer complications and a higher quality-driven reimbursement rate, whereas the other organization could endanger its reimbursement rate. 

5. The migration could also dissuade provider participation in such models for fear of losing revenue. 

For possible solutions and access to the entire report, click here.

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