Warning: 50,000 Medicare Patients Prove TKA Should Stay Inpatient

Exploring the dangerous trend of treating total knee replacements like outpatient partial knees and the severe implications for bundled payment models.

The Centers for Medicare and Medicaid Services (CMS) established the Inpatient Only (IPO) list in 2000 to identify surgical procedures that should be performed exclusively in an inpatient hospital setting. Requirements to assign a procedure to the IPO list included the invasive nature of the surgery, the need for greater than 24 hours of postoperative care, and the underlying physical condition of the patient. Facilities are paid for procedures on the IPO list through the Inpatient Prospective Payment System, a separate payment structure that excludes reimbursement for an outpatient in both hospitals and ambulatory surgical facilities.

While total knee arthroplasty (TKA) has been on the IPO list since its inception in 2000, advances in blood conservation, pain management, and early mobilization have resulted in substantial reductions in hospital length of stay (LOS) after TKA and have now made outpatient TKA a reality for younger patients. Additionally, with a shift toward more TKAs being performed in ambulatory surgical centers, some surgeons have advocated for a policy change to give select, healthy Medicare beneficiaries the option to undergo TKA as an outpatient.