Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA.
University of Arkansas for Medical Sciences, Little Rock, AR.
J Arthroplasty. 2020 Jun;35(6S):S28-S32. doi: 10.1016/j.arth.2020.01.007. Epub 2020 Jan 15.
In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed TKA from the Medicare inpatient-only (IPO) list. This action had significant and unexpected consequences.
We looked at 3 levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of FFS inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in admission classification of patients with TKA over time, number of QIO audits, compliance solutions for the new rule, and cost implications of those compliance solutions were evaluated.
Hospital reimbursement averages $10,122 in an outpatient facility but does not include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in hospital reimbursement varies widely (90th percentile decrease, $6725 vs 10th percentile $2048). Physician payments are the same in both settings (avg $1403). Patients with TKA not designated for inpatient admissions are not eligible for bundle payment programs. Patients designated as outpatients are subjected to higher out-of-pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. An AAHKS survey demonstrated that 45.08% were with inpatient designation only, 17.62% were with outpatient designation only, 25.39% were designated as necessary, and 10.1% were designated by the hospital. This survey showed that 66 of 374 (17.65%) patients had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of an AMC demonstrated that since January 1, 2018, 470 of 690 (68.1%) of CMS patients with TKA left in less than 2 midnights. The institution was subjected to 2 QIO audits.
There are many unintended consequences to the IPO rule application to TKA.
2017 年 11 月，CMS 最终确定了 2018 年医疗保险门诊患者预期支付系统规则，将 TKA 从医疗保险仅限住院治疗（IPO）清单中移除。这一行动产生了重大且意料之外的后果。
我们从三个层面研究了 IPO 规则对 Medicare 受益人的 TKA 的影响：2017 年和 2018 年 FFS 住院和门诊分类的全国比较；2019 年 4 月对 AAHKS 外科医生进行的调查；以及对大型学术医疗中心经验的深入分析。评估了随着时间的推移 TKA 患者入院分类的变化、QIO 审核的数量、新规则的合规解决方案以及这些合规解决方案的成本影响。
在门诊机构，医院的平均报销额为 10122 美元，但不包括医生的报酬。在住院环境下，医院的平均报销额为 11760 美元。医院报销额的差异很大（90%的降幅为 6725 美元，而 10%的降幅为 2048 美元）。在两种情况下，医生的报酬是相同的（平均为 1403 美元）。未被指定为住院治疗的 TKA 患者不符合套餐支付计划的资格。被指定为门诊患者的患者需要承担更高的自付费用。患者可能需要支付 Medicare 第 B 部分免赔额（185 美元）和 20%的共付额，以及处方和耐用医疗设备费用。AAHKS 的一项调查显示，45.08%的患者仅被指定为住院治疗，17.62%的患者仅被指定为门诊治疗，25.39%的患者被指定为必要治疗，10.1%的患者由医院指定。该调查显示，由于 IPO 规则的问题，66 例（17.65%）374 例患者接受了 QIO 审核。对一家 AMC 的评估表明，自 2018 年 1 月 1 日以来，690 例 CMS 接受 TKA 治疗的患者中有 470 例在不到两个午夜就出院了。该机构受到了两次 QIO 审核。
IPO 规则应用于 TKA 产生了许多意料之外的后果。
