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28 TOTAL JOINT SECTION These Factors Impact Knee Replacement Costs: 5 Observations By Adam Schrag A Medscape study found comorbidities aren't the only cost-increasing factors in knee replacement surger- ies. Here are five things to know: 1. Big drivers of cost are individual payment plans, hospital contracts and individual states. Fee-for-service reimburse- ment creates an incentive for over-treatment and causes CMS to ask medical centers to accept lump payments for episodes of care. 2. Many orthopedic surgeons believe patients at a higher risk for complications should pay more for treatment. David Fish- er, MD, of Indianapolis-based OrthoIndy said in the report, "The concern is that we start rationing care and not providing procedures to high-risk patients." 3. Researchers found longer hospital stays, discharge to a skilled nursing facility and complications all increased cost but altogether only made up 14 percent of the total cost among privately insured patients. Those looking for cost-re- duction strategies should focus on what goes on in hospitals. 4. Some practices believe bundled payments are the way to go. Charlotte, N.C.-based OrthoCarolina saves $2,700 per case, reducing skilled nursing facility admissions by 6 percent, home health usage by 6 percent and dropping readmission rates from 12 percent to 10 percent, due to its bundled payments program. 5. Many medical practices could deny patients if CMS doesn't have a risk-stratification program to refer them to appropri- ate facilities aimed at improving their overall health before any type of surgery. n 8 Ethical Concerns for Total Joint Replacement Gainsharing By Laura Dyrda T here are more than 400,000 Medicare beneficiaries who receive total joint replacements every year and costs for these procedures are increasing. Initiatives such as the Comprehensive Care for Joint Re- placement program attempt to control costs through bundled payments on a 90-day epi- sode of care. An article published in the Journal of Bone and Joint Surgery examines the ethics of gainshar- ing in total joint arthroplasty as hospitals and physicians align to improve the quality and lower the cost of total joint replacements. "Gainsharing is not a new concept in orthope- dic surgery, but its inclusion in CJR is its most impactful implementation. However, there are ethical concerns that arise when instituting a program of incentivized financial partnerships between surgeons and hospitals," according to the article. e CJR bundled payment program began for hospitals in 67 regions across the United States in April 2016 and included voluntary gain- sharing arrangements between hospitals and collaborators, some of which were physicians. Here are a few of the potential ethical issues physicians face in the gainsharing model: 1. Physicians may change decision-making about patient care when financial incentives are involved, whether they do it consciously or unconsciously. 2. Since the device cost is among the most ex- pensive aspects of surgery, the hospital and surgeon attempt to negotiate with device manu- facturers on better pricing. If device companies can't meet the desired price point, surgeons may decide to switch devices and use an implant sys- tem they're less comfortable with. 3. Physicians could face malpractice liabilities if they use less expensive devices that lead to patient harm. 4. Organizations that implement gainsharing must ensure quality doesn't slip. It's incumbent on the providers to make sure there is clinical equivalency between two resources with differ- ent costs and ensure any gainsharing arrange- ments are compliant with the DOJ and OIG regulations. 5. Providers must weigh whether increased costs upfront could lead to lower costs in post- surgical care and how short-term costs can im- pact long-term savings in terms of the technol- ogy survivorship and clinical complications. A more expensive implant that lasts longer and leads to fewer complications could save on the back end. 6. e patient's role in decision-making can also impact gainsharing arrangements. Cur- rent gainsharing models don't take patient preference into account. 7. Gainsharing models incentivize physicians to minimize risk, and those who are at a higher risk for complications or may need additional post-surgical care are in danger of not receiv- ing the care they need. 8. Orthopedic device manufacturers are con- cerned gainsharing measures could stifle inno- vation as the companies aren't incentivized to invest in research and development. e gain- sharing model may also make it more difficult for small companies and start-ups to break into the market with new technology. "e important concerns discussed in this re- view must be addressed by implementation of the proper safeguards, including monitoring by legal oversight bodies such as the OIG and DOJ," concluded the article's authors. "Sur- geons must also ensure that clinical decisions made for short-term gain do not have adverse long-term consequences." n