REGULATORY REVIEW: Driving Quality in ASC Total Joint Procedures

Regulatory Review

Driving Quality in ASC Total Joint Procedures

Certifications, data collection and AJRR reporting are key

Regulatory Review

Payers, both public and commercial, have taken intense interest in total joint procedures in recent years.

Regulatory Review

Driving Quality in ASC Total Joint Procedures

Certifications, data collection and AJRR reporting are key

As technology and new techniques expand the possibilities for outpatient surgery, few procedures have been the focus of as much discussion as total joint replacements (TJR). The rise of these procedures—in demand, performance and overall spending— has been nothing short of meteoric.


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According to an October 2017 article in PubMed, “Outpatient Total Joint Arthroplasty,” between 2012 and 2015, elective TJR procedures, also called total joint arthroplasty or TJA, went up 47 percent. New research presented this year at the 2018 Meeting of the American Academy of Orthopaedic Surgeons (AAOS) projected that the number of total hip replacements (THR) and total knee replacements (TKR) will grow by 171 percent and 189 percent respectively by 2030, according to a March 2018 AAOS release. The US already has the highest incidence rate of total knee arthroplasty (TKA) in the world, according to a November 2017 PubMed article, “Projected Increase in Total Knee Arthroplasty in the United States—An Alternative Projection Model.”

It is no surprise then that payers, both public and commercial, have taken intense interest in total joint procedures in recent years. In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced the Comprehensive Care for Joint Replacement (CJR) reimbursement model, a new initiative by which Medicare would pay a single price for all related services in a 90-day period for TJRs, rather than reimbursing for each service separately. This model, called a “bundled payment,” seeks to incentivize physicians to manage resources and coordinate care with all providers involved in a TJR procedure, according to a July 2017 PubMed article, “Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality.” This Medicare model was aimed at hospitals, but total joint procedures are by no means performed in hospitals only; many ASCs already perform total joint procedures, and with the aforementioned volume explosion on the horizon, it is clear that ASCs will play an enormous role in providing these services in the decades to come.

This raises certain fundamental questions: How will the ASC community ensure that the high standards of quality are upheld for these complex procedures? Will we see differentiated payer designs similar to CMS’ CJR model? How do we capture data to get the most accurate picture of volume and quality in a rapidly changing market? Several organizations, including commercial payers, accrediting organizations and specialty registries have already begun the important task of answering these questions.

Rewarding Quality: Accreditation Certifications and Payer Designations

A good place to begin would be with the accrediting organizations that already ensure that ASCs meet the regulatory and operational standards necessary to deliver high-quality care. In response to demand from facilities and payers seeking a way to distinguish specific ASCs as high-performing centers for TJR procedures, both The Joint Commission and the Accreditation Association for Ambulatory Health Care (AAAHC) have launched orthopedicspecific certifications.

The Joint Commission established its Advanced Certification for Total Hip and Total Knee Replacement (THKR) in 2016 and awards the certification to ASCs that undergo a rigorous onsite evaluation and uphold a number of high standards leading to improved patient outcomes. In November 2018, AAAHC announced the launch of its own Advanced Orthopaedic Certification program designed specifically for ASCs. The program, developed with the input of a multi-disciplinary technical panel, designates those ASCs that demonstrate an ability to translate effective leadership and integrated care throughout an entire episode of care, including post-discharge, into excellent clinical outcomes. These certifications allow ASCs to confidently show both patients and payers that their facility is committed, via a consistent, clinically proven, integrated care approach to performing orthopedic procedures at the highest possible level.

The introduction of distinct TJR certifications also signifies macrolevel shifts in the outpatient surgery market, specifically, that the number of ASCs performing TJR procedures has reached the critical mass necessary to demand a special signifier for centers providing the highest, most consistent quality of care.

Commercial payers also have sought to recognize and reward high-performing ASCs. In 2006, the Blue Cross and Blue Shield (BCBS) Association launched its Blue Distinction Centers for Specialty Care program. This mark of excellence is awarded to facilities demonstrating expertise in several specific specialties, with a distinct designation for knee and hip replacements. In 2019, the program expanded to include ASCs and notably requires applying ASCs to hold one of the previously described TJR credentials from The Joint Commission or AAAHC. The BCBS Blue Distinction Center designation also qualifies facilities for Anthem’s Centers of Medical Excellence (CME) designation. Aetna has its own Institutes of Quality (IOQ) designation. This is awarded to facilities that meet requirements related to quality, value and network access.

Capturing Data

The final piece of the puzzle is data. That data needs to allow the ASC industry to examine and reflect on volume and quality of total joint procedures. The American Joint Replacement Registry (AJRR), part of AAOS and an ASCA Affinity Partner, is the primary national registry accumulating data on TJR procedures. Registries are programs that collect voluntary data from health care entities, generally focused on a specific condition or diagnosis. They provide valuable insights into high-level trends— such as procedure incidence rate over time—and document outcomes that can showcase a facility’s high performance to patients and payers. AJRR has been designated a Qualified Clinical Data Registry by CMS since 2014 and is the largest orthopedic registry in the world, according to AJRR’s 2018 annual report, capturing 1.4 million procedures in 2018 alone.

Only seven ASCs submitted data to AJRR in 2017—down from a peak of eight centers in 2016—but those facilities did report more than 800 total cases of total hip and total knee arthroplasty.

Growing procedure volume submitted to AJRR will be crucial in future years for the ASC industry, particularly as CMS considers adding TJR procedures to Medicare’s ASCpayable list. The Joint Commission recently announced that participation in AJRR will be a mandatory requirement for their THKR certification. The data accumulated in AJRR will allow stakeholders to compare ASC performance in TJR procedures across sites of service and, hopefully, show the growing role that ASCs play in meeting the increasing need for TJR procedures overall.

ASCA maintains strong relationships with all the organizations mentioned and has and will continue to advocate at CMS for the safety and efficacy of moving total joint procedures to the ASC setting. Research shows that with the right processes, total joint procedures can be done safely and cost-effectively in outpatient settings. For more information on total joint procedures and ASCA’s advocacy on this topic, write Alex Taira.

Alex Taira is ASCA’s policy analyst. Write him at