The development and implementation of evidence-based appropriateness criteria may help reduce costs associated with an increase in elective procedures.
NATIONAL REPORTS-Experts are calling for the development and implementation of evidence-based appropriateness criteria for elective procedures. The criteria would be integrated into the reimbursement and care delivery systems to help reduce costs associated with the expected increase in elective procedures.
More than 1 million of these procedures were performed in 2009, according to Archives of Surgery (December 2011).
A national obesity epidemic and an aging population are to blame for accelerating the demand for joint-replacement surgeries, according to Hassan Ghomrawi, assistant professor of public health, Weill Cornell Medical College and lead author of “Appropriateness Criteria and Elective Procedures-Total Joint Arthroplasty” published in the New England Journal of Medicine (Dec. 27, 2012).
“The baby boomers coming onboard with Medicare will have access to total joint replacement,” Ghomrawi says. “They will all be aging at the same time and demanding these elective surgeries.”
According to the Pew Research Center, roughly 10,000 baby boomers are turning 65 every day in the United States, and the trend will continue for the next 19 years.
The expansion of health insurance coverage under the Patient Protection and Affordable Care Act will also cause a significant increase in elective surgeries. In fact, Clinical Orthopaedics and Related Research (October 2009) estimates that the demand will quadruple over the next two decades, exceeding 4 million operations by 2030.
“Some of the newly insured who have osteoarthritis are going to be thinking about the option of total joint replacements, and are going to utilize it,” Ghomrawi says. “We haven’t quite figured out osteoarthritis from A through Z, but I think there’s enough evidence out there from radiographic assessment, surveys, clinical exams and MRI findings for a clear assessment on when an osteoarthritic knee needs surgery.”
For most common elective procedures, appropriateness criteria have not been created. Current cost-savings proposals have focused primarily on payment reforms, such as pay for performance and bundled payments. However, because elective procedures are not always time-sensitive, being able to prioritize patients has the potential to reduce costs and slow the growing number of elective procedures performed.
“[Joint replacement] is being utilized by people who have different levels of disability, different levels of radiographic osteoarthritis, and some of them can be prioritized to be done today, and some of them could be delayed,” Ghomrawi says.
He also says that some patients might not even need surgery because less intensive therapies could provide a better alternative.
“They might lose weight, or they might utilize other treatments that have debatable benefit to either avoid the surgery or delay even more,” he says.
NO REIMBURSEMENT, NO SURGERY
Ghomrawi and his co-authors found that when health insurers did not reimburse elective procedures that were deemed unnecessary or inappropriate, a minority of patients were willing to pay out-of-pocket. They also found that savings could be realized from a reduced incidence of complications associated with fewer surgeries.
“What we’re proposing is something that is ambitious,” Ghomrawi says. “It requires people from across the spectrum of total joint replacement to come together to develop and use this criteria.”
Ghomrawi says the clinical community must come together as professionals and ensure that care that is necessary for patients is not affected by economic incentives. MHE