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Discussion on the Shift of Inpatient to Outpatient [WEBINAR]

Lia Cirelli and Lila Kelso


November 18th, 2021

Avant-garde Health hosted a November Fireside Chat with Errol Norwitz, MD, PhD, MBA, CEO and President of Newton-Wellesley Hospital, Lowry Barnes, MD, Chair of Orthopaedics at University of Arkansas for Medical Sciences (UAMS), and Charles Davis, MD, Division Chief of Arthroplasty at Penn State Health Milton S. Hershey Medical Center. The discussion centered around the ongoing shift from inpatient to outpatient care, with an emphasis on Medicare reimbursement in the field.

https://vimeo.com/642081686/9c13780341

During the chat, Dr. Barnes, Dr. Davis, and Dr. Lowry were asked about where they saw Medicare going after their recent pause on eliminating the inpatient-only list. They explained that many total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) are already performed with a short length of stay, and believe that they will continue to remain off of the inpatient-only list. When looking at spine cases, however, the group noted that they are often more complicated and might remain on the inpatient-only list. Additionally, DRG payments and outpatient payments vary dramatically at academic medical centers (AMCs) (with a noted ⅓ decrease in payments between the two), as payments for things like education disappear, causing margins to thin at AMCs. This reduction in payment has led many organizations to build out new orthopaedic facilities, including ambulatory surgery centers (ASCs).

One concern that participants noted is that many quality metrics are based on inpatient procedures, which can have a negative impact on a hospital’s performance in the eyes of Medicare. Given the shift to outpatient care for many orthopaedic cases, those receiving care in an inpatient setting (and therefore counting toward quality metrics) are often the most acutely sick, causing worse outcomes at surface level. All three panelists agreed that CMS needs to ensure that incentives are aligned properly to the shift to outpatient care.

More positively, panelists noted that patients themselves are in favor of shifts to outpatient care, as they can recover more comfortably at home. In addition, panelists noted that overall, medicine has gotten better at ensuring good patient recovery when compared with 8-10 years ago. It was noted that attention needs to be paid to those who do not have support systems at home, as they might be more quickly discharged to settings that do not allow for adequate recovery in a supportive environment. Additional focus on case management, social work, and community for older patients (an aging population that is more likely to get TKAs and THAs) can help to ensure positive outcomes upon discharge while allowing for AMCs to take on more acutely sick patients.

Overall, panelists noted that CMS needs to better align incentives for medical providers and patients when thinking about what to do next with the inpatient-only list. By ensuring that the proper patients receive outpatient care, organizations can guarantee that their inpatient areas are reserved for those who most acutely need intensive care while adapting to changing revenue models based on decisions from CMS.

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