Total Joint Replacements Unwise for ASCs

Original story posted on: August 2, 2017

My Monitor Mondays segments are usually either informational, centering on a new policy or proposal, or one of my rants, often criticizing someone for something. But on the July 31 report and in this article, I wanted to start with one and move to the other.

First, my rant. OK Centers for Medicare & Medicaid Services (CMS), we have had enough with your name changes. You weren’t happy being called the Health Care Financing Administration (HCFA), so we stood by while you changed your name to CMS. You introduced the Physician Quality Reporting System (PQRS) to reward physicians for reporting quality measures but then you inexplicably changed it to the Physician Quality Reporting Initiative (PQRI). You wanted to reward hospitals for efficient care of their total joint patients, so you proposed the Comprehensive Care for Joint Replacement (CCJR) but then when finalized you called it CJR. And now you have decided to remove social security numbers from beneficiary ID cards – you smartly called it the Social Security Number Removal Initiative (SSNRI).

But I guess SSNRI sounded too much like the antidepressants that we all will need to take when our billing systems are unable to handle the new identifiers, so you are now calling the project “the New Medicare Card.” That’s right, that’s not the name of the card; it is the name of the initiative to change the card. Or maybe it is the name of the card and the name of the initiative to change the card.

With the many hospital system consolidations and name changes, and the importance of brand recognition, I can see the desire to find a name that is catchy, but come on, CMS; pick a name and stick with it.

On the information front, I want to inform you that CMS is now accepting comments on the 2018 Outpatient Prospective Payment System (OPPS) rule. As I reported, moving total knee replacement off the inpatient-only list is in all likelihood a done deal, but allowing total joint replacements at ambulatory surgery centers (ASCs) is absolutely up in the air, as is allowing partial and total hip replacements at ASCs.  

So now is the time to tell CMS that it is not safe to allow total joint replacements to be performed on Medicare beneficiaries in freestanding surgery centers. To submit a comment, you can go online to and search for CMS 1678. Click “search” and the top result will have a box for comments. You can also use this link.

Remind them that most Medicare patients have comorbid conditions that require monitoring throughout their immediate post-operative course, and many ASCs are not fully staffed at night and do not have a 24-hour physician presence. Many freestanding surgery centers are unable to give blood transfusions, requiring a transfer to a hospital if blood is needed. Allowing such an invasive surgery in a non-hospital setting has the potential to endanger the health of beneficiaries and does not meet the standard CMS has outlined in its rules for surgeries to be safely performed at a surgery center. Furthermore, ASCs also are limited to 24 hours of total care; will these surgery centers be discharging the first surgery patients of the day the next morning by 7 a.m.?  

Yes, technology and techniques are improving, but until scientists figure out how to stop aging, I think joint replacements among the elderly should be done in a hospital. I’d also like to suggest that you comment that removing total joint replacements from the inpatient-only list is certain to exacerbate the skilled nursing facility (SNF) access problems we are already facing with the three-day inpatient admission requirement, and suggest that CMS work with Congress to fix this longstanding issue as well.   

Ronald Hirsch, MD

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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