Developing an Effective IP Hip and Knee Joint Program 

By Bernard J. Emkes, MD

Just because anterior hips and routine total knee replacements are no longer on the IPO / MIO list does NOT mean that many of those patients cannot be statused as IP when appropriate. 

MCG indicates that some ideal patients can be done as OP / OBS, but many can or should remain IP. However, with the Traditional Medicare 2 MN rule to get to IP, and MA plans needing to Prior Auth IP stays, it is more important than ever to develop a process to admit as Inpatients those who justify IP admission, while doing some or even many procedures as OP / OBS when it is relatively safe to do so based on patient risk assessment. 

This is exemplified by a leading national status expert saying that - All hip and knee patients need to have status confirmed and authorized prior to admission. That is an ideal state. 

But for that to happen, there will need to be a concerted effort by Hospital Administrations, Orthopedic Groups, Surgery Evaluation Centers (SEC), UM teams and Case Managers to develop processes unique to every facility in order to assure success. There will be added costs to implementing these processes, so business cases will need to support any enhanced programs. Incremental progress may be needed before getting to a fully implemented, comprehensive program. The change should be easily supported due to the normally higher reimbursement for IP vs OBS surgical procedures. Each facility must do their own assessment. 

How does one get to the point of having a confirmed status for each patient prior to the scheduled surgery date? 

One hospital is in the process of further solidifying an already solid process. During the pre-op surgical evaluation a careful H&P is done to identify high risk diagnoses that increase risk for the proposed procedure. Based on that calculated higher risk, Medicare Advantage plans are approached to approve IP status prior to admission. Many are approving IP when convinced of the increased risk. 

Diagnoses that might impact the need for IP are – poorly controlled diabetes (high A1c confirms this), OSA (on CPAP?), COPD (what level of home treatments), active CHF (active meds), poorly controlled hypertension (multiple meds), history of CAD / CABG (maybe), immunocompromised status (on steroids or immune suppressing meds), and active cancer treatment that would also likely render a patient immunocompromised. This is NOT an all-inclusive list. Success is defined by having MA plans approve the procedure as IP prior to admission, and proper documentation by Ortho or the SEC of the need for IP. 

Unfortunately, not all Ortho docs refer their patients to a SEC prior to admission. This is going to be an awkward gap unless the docs and their scheduling staff are educated regarding these concepts. 

All that said, it becomes obvious that traditional prior auth processes used by medical offices will not meet this need. There are non-clinical persons doing the scheduling with hospitals and health plans. Unless they have clinical support to assist in these requests (as described above) this process will not work. This is part of the added costs needed to support this program. The exact mechanism of how each facility and associated Ortho groups evolve these processes must be determined locally. 

There are additional opportunities for coordination between physician advisers, UM nurses, Case Managers, and others before and after the surgical care is rendered. 

Implementation of these programs is time and resource intensive. There is a need for careful discernment, review of relative opportunities, and a clear need for close alignment between all involved parties to create a successful program.