Hospital for Special Surgery Perspectives

How to Control Costs With CMS's Knee Replacement Bundles

Charles N. Cornell, MD


January 25, 2017

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I am Charles Cornell, an orthopedic surgeon at the Hospital for Special Surgery in New York. I want to talk about delivery of quality care in total knee replacement with respect to bundling and cost savings.

Total knee replacement is one of the most common and most successful procedures performed in the United States and around the world. In 2009, we performed over 650,000 total knee replacements in the United States. It is projected that we will be performing over 1 million in the coming years. In 2009, in spite of the fact that there was very high patient satisfaction and low complication rates with total knee replacement, we spent over $9 billion.

The Centers for Medicare & Medicaid Services (CMS) is very interested in reducing the cost of delivery of care for total knee replacement. CMS's Episodes of Care Project has placed a burden on hospitals and providers to control that cost. They have done this through a program of cost bundling so that hospitals and providers are reimbursed with a single reimbursement, with the risk for cost carried by the hospitals and the providers.

We have been looking at our data, and we found that two factors pose the biggest risks for added costs. One is the occurrence of complications that require transfer of patients to a higher level of care, or for readmission to the hospital. The other is for patients being discharged to skilled nursing facilities for rehabilitation.

Over the past decade, with clinical care pathways that make care more efficient and more standardized, we have been able to reduce our length of stay from 7 days in 2006 to 3 days now. We have done this by encouraging patients to be better prepared for surgery and to be discharged directly to home—and to having physical therapy at home, avoiding the expense of a skilled nursing facility stay.

This approach requires a multidisciplinary team. The project has to start before surgery, and there has to be a very organized approach to medical preparation and optimization of patients. The discharge plan has to be determined in advance, and the patient and family have to be involved in that plan.

We have had to establish partnerships with medical delivery services in our communities. We have taken advantage of working with the Visiting Nurse Service of New York to provide intensive home physical therapy after discharge. It is designed to replace physical therapy that the patient would otherwise obtain in a skilled nursing facility; provide close follow-up of patients during the first 2-3 weeks following discharge; and coordinate thromboembolic prophylaxis, physical therapy, pain management, and follow-up surgical visits.

Perhaps the biggest opportunities we have had have been in these two areas: preoperative preparation and discharge to home.

The literature clearly shows that there is no advantage to discharge to skilled nursing facilities. There have been multiple studies performed, including Cochrane Database reviews, that show that there is no difference in outcomes whether a patient has acute postop or skilled nursing facility rehab after discharge compared with being discharged to home and getting rehab there. The evidence that we should move beyond discharge to skilled nursing facilities and encourage our patients to be directly discharged to home is encouraging.

Our collaboration with the Visiting Nurse Service of New York has been very successful. We have been able to collect and look at the data over the 2 years of our program, and our readmission rates are very low—under 2%.

The other area that we have gained a lot of advantage in has been in our preoperative preparation program, in which we identify patients according to their risk for surgery. We stratify their surgical risk and then place them into coordinated care plans on the basis of that risk. If patients are low risk, they are moved through the surgery quickly. Their preoperative clearance process is expedited. They do not require a lot of preparation for surgery.

In contrast, those patients who have significant medical comorbidities—such as diabetes, coronary artery disease, pulmonary disease, or even obstructive sleep apnea, or who are obese, smokers, or have a history of use of narcotic medications—require special attention in the preoperative period. We have set up a program in which these patients enter into the preoperative process approximately 6 weeks before surgery, where their medical condition is optimized.

For example, patients with diabetes whose A1c reflects that their blood sugar is high—greater than 8—are not scheduled for surgery. They are referred to their endocrinologist and put in a program to reduce their blood sugar and get it under better control. They are then returned for surgical scheduling. Patients with obstructive sleep apnea are encouraged to have a preoperative evaluation and get treatment. Patients who are on narcotics are seen by our chronic pain specialist and weaned from the narcotic medication before surgery. It is through this process that we hope that we will reduce postoperative complications in this high-risk patient group—and reduce the number of readmissions, which is the primary driver of cost.

We are in the process of developing a surgical risk tool that can be accessed online. It is automatic and will make it easy for the surgeon to apply so that his or her workload is not increased at that first initial consultation visit, when this assessment should be performed.

Efforts to move toward ambulatory total joint replacement in the United States have illustrated how important it is that this multidisciplinary approach be enacted. Institutions can only achieve that if their care processes are optimized. I think those principles also apply to those patients who are going to have an inpatient stay and be involved in these bundle payment programs.

In our initial bundling program with CMS, we were not that successful in recouping costs. But as we coordinated these efforts and moved to a multidisciplinary team to prepare patients better and to better plan discharge, we have become much more successful.


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