Site of Service Shift in Total Joint Replacements

Ambulatory Surgery Centers (ASCs), a subset of outpatient healthcare facilities that focus on same-day surgical procedures, have surged in popularity in recent years. The global ASC market was estimated to be over $81 billion in 2020 and is projected to increase to more than $120 billion by 2027. In the United States alone, ASC markets are expected to reach $36 billion by 2023. This growth is due in part to the shift of total joint replacement procedures from inpatient to outpatient settings. This trend was initially fueled in the US by the 2018 Medicare decision to remove hip and knee total joint replacements from the inpatient-only procedure list, thereby transitioning joint replacements to an outpatient setting. Total knee replacement became eligible for Medicare payment in the ASC setting in 2020 when CMS added the procedure to the ASC-payable list in its 2020 Medicare Hospital Outpatient Prospective Payment System and ASC Payment System Final Rule. The Ambulatory Surgery Center Association (ASCA) reported an Sg2 study in which total joint replacement outpatient trends were expected to increase from 15% in 2018 to over 50% by 2026. This shift to outpatient is consistent with current trends of ASCs performing increasing numbers of total joint replacements year-over-year.

Which Patients are Best-Suited for ASC Procedures?

There are many factors that influence ASC eligibility, including age, insurance information, and patient health comorbidities. It is important to take these and other factors into account when establishing risk criteria and identifying which potential patients are low-risk and therefore good candidates for ASC procedures. According to one study of 2016 total knee replacements without major complications, 48% of patients met those low-risk criteria. Another found that 52% of total joint replacement patients report a 1 to 2-day length-of-stay. This abbreviated stay makes them potential candidates for ASC procedures, as these medical centers specialize in efficient surgical care. Studies have also shown that quality remains the same for ideal candidates regardless of location. It has been predicted that there will be a 153% increase in knee replacements by 2050 overall, while inpatient growth for these procedures will only be around 3%. Most of the growth in knee replacement will be done in an outpatient setting with the largest increases seen in the ASC setting.

There are multiple ways to encourage patients to have a discussion with their doctors to determine if surgery in an outpatient setting would be right for them. ASCs usually will have a lower out-of-pocket expense for the patient when compared to identical procedures performed in an inpatient or outpatient setting. Lower out-of-pocket costs for the patient can provide a strong incentive for them to consider outpatient surgery at an ASC over the traditional inpatient setting. Nationwide, employers are increasingly building ASC services into their benefits for eligible patients, through incentives and/or precertification criteria. This expanded coverage can also lead to lower costs for prospective patients, which makes outpatient ASC procedures even more viable.

Same Quality of Care at a Lower Cost

By partnering with providers who want to lower health care cost trends, payers have the opportunity to deliver quality care to their members at a lower price point.

One study from New York City-based Hospital for Special Surgery and Philadelphia-based Rothman Orthopaedic Institute compared knee and hip replacement outcomes and costs for both inpatient and outpatient surgery. Surgery costs for the ASC group were 40% less than inpatient surgery costs without any significant difference in readmission and complication rates. Enlace Health’s Episode of Care expertise facilitates value-based care programs that incentivize total joint replacement shifts in care when appropriate. We see within our own clients’ data that this site of service shift can help build a competitive bundle program that promotes reduced costs and high-quality outcomes for members. Total joint replacements are quickly shifting to outpatient settings, including to ASCs, and our Episode of Care expertise prepares clients for this fast-arriving future.

Enlace Health’s solutions help healthcare payers and providers design, implement, and administer value-based programs. Together, we are simplifying value-based healthcare


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