John Dunleavy, MD Matt Searles, Merritt Healthcare Bill Mulhall, Merritt Healthcare Kerri Ubaldi, Merritt Healthcare Matt Kilton, Eveia Health Consulting OCTOBER 15, 2015

 Benefits & Challenges with Joint Replacement in the ASC  Joint Replacement Overview  Operative considerations  Staff training  Clinical requirements to consider  Current reimbursement considerations and hurdles

 Pain Control  Physical Therapy  Previous potential need for blood transfusion  Reimbursement  Getting the patient onboard

 The ASC is a highly specialized and controlled environment  Less rigid and more cost ‐ effective setting than that of a hospital  Patient satisfaction is higher  Significantly lower infection rates  Advances in surgical technique, implants, comprehensive blood management, and pain management have eliminated the need for an overnight hospital stay

 -Concept: Resurface only symptomatic area  -Even if some wear exists elsewhere  -Increasing in popularity  -Less surgery than TKA  -No ligaments removed = knee “feels more like a normal knee”

Degenerative kneeCutsImplant componentsImplanted

With TKA, the damaged knee surfaces will be resurfaced with metal and plastic implants. The selected implants are sized to the patient’s specifications.

 Patient-specific TKA  Pre-op 3D imaging used to reverse engineer unique cutting guides  Allows surgery through smaller incision  Less surgical trauma = less pain / quicker recovery

 Technology here to stay  Allows more accuracy  Importance unclear  “Makoplasty”  Blue Belt

HIP ANATOMY:  Socket  Ball  Femoral neck  Smooth weight- bearing surfaces  Smooth cartilage  Femur

Cuts Implant components Implanted

 Increasingly popular  No muscle detachment  Improved immediate post-op function  No post-op “hip precautions”  May use x-ray during surgery  Not for everyone

 Still most common  Incision length greatly reduced  Some muscles detached from femur bone  Historically higher risk of dislocation  Hip precautions

 Physician and staff meetings to evaluate needs (anesthesia involvement is key)  Good understanding of supplies and equipment required  Obtain written policies and protocols, physician orders  Consider sending staff to an ASC that currently does total joints to observe  Mock total joint procedure

 Establish what your needs are & what they can provide  Determine postoperative physician orders for nursing & PT  Determine timelines for visits the day of the procedure  Transfer of physical therapy back to the physician practice if necessary

Non-smoker No diabetics No bleeding disorders or anticoagulant therapy No liver disease BMI parameters to be determined – recommending BMI<30 No sleep apnea of any degree No history of stenting or cardiac surgery No history of arrhythmias ASA Class I or II only No narcotic dependent patients No oxygen dependency, COPD, or other pulmonary disease No urological issues (enlarged prostate, chronic UTI) Intact skin integrity (no psoriasis outbreak, chronic dermatitis) No unresolved dental issues

 H&P  Medical clearance  Labs (CBC, CMP, PT/INR)  EKG  MRSA swab

 Verify medical history  Identify patient education needs  Evaluation of the home environment  Identification of available family members

 Assess the patient’s knowledge and understanding  Review basics of operative procedure  Teach or provide prescribed preoperative skin prep  Review operative day process  Review the role that the VNA will have – nursing & PT  Explain necessary postoperative activity restrictions.  Provide or reinforce teaching of postoperative exercises  Teach respiratory hygiene procedures  Discuss postoperative pain control measures

 PACU stay on average is 2-3 hours  Vital signs monitoring  Assess pain level – manage pain  3 rd dose of antibiotics given  Incentive spirometry  Sequential compression devices  Encourage to sit up, dangle the legs, ambulate to BR  Start a light, high fiber diet

 Pain Management  Swelling  Incision Care  Temperature / Fever  Activity

 Patient satisfaction survey given to patient day of procedure  Follow up phone call the following day  Consider adding a phone call each day out for 3 consecutive days

 Reimbursement Environment  Existing Contract Structure  Approaching Payors to renegotiate

 Shoulder 23470,  Hip  Knee

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 Payors are beginning to implement solutions that reimburse total joints  Most are utilizing framework of their existing outpatient methodology, or a carveout  Experiencing significant variability from state to state and region to region 34

 Implant coverage varies by Payor; some pay incrementally, while others bundle implant into the procedure reimbursement  Overall Payors are still developing appropriate reimbursements 35

 Perception of generalists performing specialized services  Uncertainties with respect to recovery, pain control, therapy  Perception that clinical quality and safety may be overlooked in favor of profitability 36

Eagerness depends upon...  Hospital influences  Opportunity for cost savings  Comfort of Medical Director/Contracting director 37

 Name, license, NPI, (information to identify surgeon(s) in Payors claims system)  Hospital where case are currently performed  Anticipated case counts by payor  List of CPT codes surgeon(s) anticipate performing  Implant and general cost information  Market cost data 38