Medicare Patients Deserve a Choice: The Case for Safe, Effective, Cost-Saving Shoulder Surgery in ASCs

In this episode of the Advancing Surgical Care Podcast, ASCA Chief Executive Officer Bill Prentice talks with orthopedic surgeon and ASCA Board member David Weinstein, MD, about performing outpatient total shoulder surgeries in both hospitals and ASCs.

Tens of thousands of patients with commercial insurance undergo safe, effective total shoulder surgeries in ASCs each year, saving themselves and their insurers millions of dollars. Yet the Centers for Medicare & Medicaid Services (CMS) has refused to extend its insurance coverage to ASCs—the less costly site of care and the one that most patients prefer. Dr. Weinstein discusses several clinical studies that include findings that support making this change, as well as his own experience performing thousands of shoulder surgeries, in this compelling case for finally allowing Medicare patients the same choice that private pay patients enjoy today.

Dr. Weinstein is a graduate of the University of Colorado School of Medicine, where he completed his residency in orthopedic surgery, as well as an associate clinical professor at the University of Colorado Department of Orthopedics in Denver.

Transcript

Narrator:   0:01
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in providing safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice:   0:27
Hello, and welcome to the Advancing Surgical Care Podcast. I’m Bill Prentice, CEO of ASCA and the host of this episode. My guest today is Dr. David Weinstein, an orthopedic surgeon and a member of the ASCA Board of Directors. I’ve asked Dave to join me today to talk about total shoulder arthroplasty surgery, a procedure he specializes in as part of his sports medicine practice in Colorado Springs, Colorado. And we want to talk about why appropriate Medicare beneficiaries should be permitted to have this procedure performed in surgery centers. For the past few years, ASCA has been advocating for the Centers for Medicare & Medicaid Services, or CMS, to add total shoulder surgery to the ASC Covered Procedures List. And we were hopeful that this would be the year that CMS would acknowledge the overwhelming clinical evidence and support of doing so. Regrettably, when CMS released its draft payment rule for ASCs in July, it failed to propose allowing total shoulder procedures in the ASC setting and offered no explanation as to why. So, before we begin our discussion on this important topic, I’d like to say a little more about my guest. Dr. Weinstein is a graduate of the University of Colorado School of Medicine, where he completed his residency in orthopedic surgery. His elite training also includes two fellowships in shoulder and elbow procedures and traumatic injuries. In addition to his surgical practice today, Dave is also an associate clinical professor at the University of Colorado Department of Orthopedic Surgery in Denver, and has held several prestigious positions, including service as a team physician for several US Olympic teams. So, with that introduction, Dave, welcome to the podcast.

David Weinstein:   2:05
Thank you, Bill. Glad to be here.

Bill Prentice:   2:07
Well, I’m really hoping to learn a lot more about total shoulder from you. So, I think as a starting point, it would be helpful for our listeners if you could briefly talk about the advances in anesthesia, surgical technique and postoperative pain management that have allowed total shoulder surgery to become a safe and appropriate procedure for the outpatient setting.

David Weinstein:   2:27
Well, thanks, Bill, I appreciate the opportunity to speak to this. This is one of my passions and a big part of my practice doing shoulder arthroplasty. It’s interesting because shoulder arthroplasty is significantly increasing in numbers. In fact, the incidence is increasing twice as fast as total knee replacements and three times as fast as total hip replacements. So, it’s something that’s growing in number and really has a lot to offer to our patients. A lot of the ability to perform these arthroplasties has been advanced by new techniques, as you just mentioned, and pain management, the anesthesia we’re able to provide, and then our medical preparation of the patients. One of the exciting things to me is in the last three to four years has been the development of some long-acting anesthetics. So, in the past, we would give a patient a general anesthetic; more recently in the last 10 to 15 years, we would add a nerve block. Now we have some newer agents—local anesthetics that will last 48 to 72 hours. That gets the patients through the most painful part of the procedure without needing narcotic pain medication, making it safer and more predictable for the patient. It’s also reduced the amount of general anesthesia they need, so the old days of waking up nauseated, tired and unable to get out of bed and go home have been pretty much put to rest with some of our newer techniques with anesthesia. A lot of these are done under ultrasound and all types of techniques that can be done in an outpatient setting. The other thing you mentioned was pain management. So, one of the barriers to surgeries is how do we manage pain? We all know that there is a definite pain medication problem in this country. So, anything we can do to reduce the narcotics, and that’s where both the techniques of our anesthesia, being able to place the blocks under ultrasound in the proper position, as well as the use of these longer-acting local anesthetics has really reduced the amount of medications we prescribe. There’s been some advancements in ice machines—these are compressive machines that allow continuous circulation of ice, which is one of the other main pain controls that we use and obviates the need for narcotic pain medication. And there’s been also some advances in some of the medicines that are nonnarcotic, some better tolerated anti-inflammatory medication as well as nonnarcotic pain medication.

Bill Prentice:   4:42
Wow, that’s a lot.

David Weinstein:   4:44
That is a lot.

Bill Prentice:   4:46
I actually once had a friend who had shoulder surgery a couple of decades ago and he was a miserable person for days and I think he would have much preferred to have had the care that you’re providing now than what he received then.

David Weinstein:   4:58
I think it’s made a big difference. I unfortunately have had my own experience with having my rotator cuff fixed, which I think is actually a more painful operation than a shoulder replacement, and managed it with Motrin, and I think it’s because of our newer techniques.

Bill Prentice:   5:11
That’s amazing. Well, as you know, there are thousands of total shoulder procedures being performed safely, conveniently and effectively in surgery centers today, but unfortunately, only on commercially insured patients. There are also tens of thousands of Medicare patients receiving total shoulder procedures on an outpatient basis, but only in hospital outpatient departments, or HOPDs. As someone who’s performed surgery in both types of facilities, can you speak to the similarities between ASCs and hospital outpatient departments? And whether or not there’s any rational basis for CMS to distinguish between the two as it relates to the procedures being performed on a relatively healthy patient?

David Weinstein:   5:54
Yes, I have trouble understanding why we can perform total knees and total hips in an ambulatory surgery center but not total shoulders. Total shoulders have a lower risk factor—patients can get up and walk and that alone reduces the risk of blood clots and respiratory problems. So, that’s probably one of the biggest differences between an upper extremity procedure and a lower extremity procedure. I perform almost all my patients that have commercial insurance in an ASC setting for several reasons. One is there’s just a higher patient satisfaction. There’s less bureaucracy to deal with for the patients, they find it a better experience, it’s usually more of a one-on-one nursing care than they can get at a bigger hospital. So, that’s one part of it that I think is very helpful. Also, know that there’s substantial cost savings involved in doing things in a surgery center. There’s a very good study from JBJS, which is our main source of literature in orthopedics, that shows savings anywhere from $1,000 to $52,000 depending on which study you look at, so that’s pretty significant. And then most important to me, I find that it’s just equally as safe to perform them in a surgery center as it is in the hospital. There’s good data that now shows that there’s no difference in the complication rate, the readmission rate, whether you’re performing in the hospital or you perform them outside the hospital. There’s also a lower infection rate in an ambulatory surgery center because, again, there are not a lot of unhealthy patients there. So, in part, we’re cutting out some of the patients because we’re operating on more healthy patients, but it’s also a safer environment for our patients.

Bill Prentice:   7:32
Well, thank you, Dave. If you don’t mind, we’re going to take a break here to hear a message from our podcast sponsor. We’ll be right back.

Narrator:   7:39
This episode of the Advancing Surgical Care Podcast is brought to you by AMSURG, a national leader in the strategic and operational management of ambulatory surgery centers. AMSURG partners with more than 2,000 physicians and health systems and more than 250 ASCs operating in 34 states. Learn more by visiting amsurg.com.

Bill Prentice:   8:00
So, Dave, before the break, we were talking about the efficiency of the ASC setting and how appropriate it is for more patients that are currently going there. An interesting fact is that, in terms of Medicare beneficiaries, half of them are under the age of 75 and a third of them have no chronic health conditions that would put them at risk for outpatient surgery. So, allowing them to choose an ASC for their surgery is going to save the Medicare program millions and millions of dollars a year. So, I think the comments you made about the efficiency of the ASC setting are really, really important. And so, how important is that in terms of trying to control costs for Medicare?

David Weinstein:   8:44
Well, we should all be concerned about the healthcare system and the finances that go along with it. And clearly, it’s a more efficient process that lowers costs. And if you can get the same product with equal outcomes but do it for less money, it makes sense to put it in that setting. And again, I can’t overestimate the value that patients find about being in a surgery center just as far as their own satisfaction, their ability to save. There is a study that showed they looked at patients that had had one arthroplasty in an inpatient setting and one in an ambulatory surgery center and 94% of the patients said they’d rather have it back in the ambulatory surgery center, that was a better experience. So, I think that’s an important thing as well. And then the efficiencies, of course, just drive lower healthcare costs.

Bill Prentice:   9:28
Absolutely. Well, at the outset, I mentioned that CMS not only failed to approve adding total shoulder surgery to the procedure list for us, they also failed to provide any reason why or give us any guidance on additional steps we need to take to convince them, as you’ve been doing, on the safety and efficacy of allowing ASCs to perform these procedures on Medicare benefit patients. So, what we find particularly frustrating is that these decisions on surgical procedures, or more appropriately lack of decisions, are being made by a handful of CMS clinicians, most of whom are not surgeons. And I’m sure you’d agree that as the attending surgeon, you are both more qualified and better positioned to make a judgement about where a particular patient can best receive the care that she requires. So, please talk to me for a minute about how you, as a surgeon, evaluate your patients who need total shoulder surgery, and how you make your determination about the appropriate site of care.

David Weinstein:   10:25
Absolutely. The ruling by Medicare has been a mystery to me because it doesn’t make any sense. There’s a lot of data now that helps us stratify which patients are safe to do and in what setting for most of our procedures. Right now, we do a significant amount of rotator cuff surgery on Medicare patients in the ambulatory surgery center, it’s really that same population that does just fine. So, to me, there should be no difference on that. There’s some pretty good data that suggests that patients that are under 75, that have a certain BMI—less than maybe 35—that don’t have a lot of significant predominantly cardiopulmonary comorbidities, are good candidates to be done in an outpatient surgery center. So, that criteria has been pretty well studied. One of the things that you have to have is family support if you’re going to do an outpatient surgery center. So, that’s important when we’re evaluating the patient. And interestingly, the data shows that men actually do a little better with an outpatient surgery center, predominantly because wives are better at helping their husbands recover than the men are at helping their wives. So, if you think about it, that probably intuitively makes sense. But there are criteria we look at that we would never want to put a patient in any danger. But again, I find that there are a lot of advantages to having the surgery done in the ambulatory surgery center over the hospital, and again, patients prefer that.

Bill Prentice:   11:45
I think that’s really important. And I think that evaluation, I mean, that’s the thing I think that CMS fails to realize is that every patient you see is being looked at through that prism of what the clinical standards are, and their health risks, and that’s what’s the determinant about where you bring them to. That it’s not just everyone who comes to you is going to go to a surgery center, you’re still doing that initial assessment, that H&P, to make sure that the surgery center is the right place for that procedure.

David Weinstein:   12:15
I’ve looked at my own patients, and currently, we screen everybody. And the biggest barrier to performing a shoulder arthroplasty in an outpatient center is the payer, since it is just Medicare and the federal products that will not allow it. So, we take those patients to the hospital. And of the patients I take to the hospital, 80% of them we send home from the hospital on the same day. So effectively, they’re getting outpatient surgery, they’re just being performed in the hospital, where, to me, there’s a higher infection risk, and there’s a higher cost, lower satisfaction. So, we’re already screening these patients and sending 80% of them out anyway. So, it is a mystery to me and I’m hopeful that with education and time that at some point, CMS is going to figure this out.

Bill Prentice:   13:00
Well, Dave, this has been highly informative. And I’m sure this will be helpful in our continuing effort to have CMS finally add total shoulder surgery to the ASC Covered Procedures List. I want to thank you for your time today and thank you for your service on the ASCA Board of Directors.

David Weinstein:   13:16
Thank you, Bill. I appreciate it.

Bill Prentice:   13:17
So finally, before closing, I’d like once again to thank our podcast sponsor, AMSURG, a leading ASC management company with more than 250 ASC partners in 34 states. To learn more about them, visit amsurg.com.