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10 things about CMS bundled-payment rule


Becker’s Hospital Review has done a handy 10 things to know about CMS’s final rule on a mandatory bundled-payment program for coronary-artery-bypass surgery and its expansion of the existing Comprehensive Care for Joint Replacement program. To read whole article, please hit this link.

Here they are, stripped down:

1. “Under the final rule, acute care hospitals in certain markets will be accountable for the cost and quality of care provided to heart attack, coronary bypass and surgical hip and femur fracture patients beginning with hospitalization and extending 90 days after discharge.”

2. “The rule expands the existing CJR model to include additional surgical treatments for hip and femur fractures….”

3. “Hospitals will receive retrospective episode-based payments under the new bundles. Hospitals that spend less than the target price for the episode of care while meeting or exceeding quality standards keep the savings achieved. A hospital is required to repay Medicare if the costs exceed the target price.”

4. “The final rule includes a cardiac rehabilitation payment model, which will test whether a payment incentive can increase the utilization of cardiac rehabilitative services….”

5. ”The heart attack and coronary bypass bundled payment model will be mandatory for hospitals in 98 metropolitan statistical areas….”

6. ”About 860 hospitals will participate in the hip- and femur- fracture bundles, which will be tested in the 67 MSAs already selected for the CJR model.”

7. ”The cardiac rehabilitation payment model will be implemented in 90 MSAs, 45 of which were not selected for the heart attack and coronary bypass models….”

8. ”The cardiac bundles and the expanded CJR model qualify as Advanced Alternative Payment Models under the Medicare Access and CHIP Reauthorization Act and the Quality Payment Program.”

9. ”The American Hospital Association said it was pleased with some parts of the final rule, including the flexibility the rule provides regarding MACRA participation. However, the AHA expressed concern about the pace of change. ‘The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months,’ said the AHA. ‘This is too much, too soon.”‘

10. The bundles will begin July 1, 2017.

N.E. Baptist signs bundled-payment pact with GE for joint replacements




New England Baptist Hospital has become  a preferred provider for hip and knee replacements in a bundled-payment system for General Electric’s 100,000 employees nationwide.

This is the first such large employer partnership for Roxbury Crossing, Mass.-based New England Baptist but it’s the seventh  for GE, which has picked  six other preferred hospitals for joint care in other states.

GE, which recently moved its headquarters from Fairfield, Conn., to Boston, will directly contract with the hospital, which will  be paid via  bundled payments that cover care spanning 60 days.

Big employers are increasingly turning to bundled payments for procedures undergone by their employees in order to cut, and better forecast, costs and improve care.

GE will pay out-of-pocket costs and travel expenses for employees who opt to have surgery at the hospital.

If there are complications within the 60 days of the bundled- payment period, there will be no other charge to GE except for the bundled amount, Virginia Proestakes, GE’s program leader of health operations, told The Boston Globe.

To read The Globe’s story, please hit this link

Smooth care transitions a point of pride for this small R.I. hospital


South County Health, a small nonprofit system in bucolic southern Rhode Island, owes a large part of its success to its ability to manage transitions of care – an increasingly urgent imperative as healthcare moves from fee-for-service to value-based reimbursement.
The system’s flagship is South County Hospital, a 100-bed community hospital. The system also includes South County Home Health Services (a home health agency); South County Surgical Supply (home medical supplies); South County Medical Group, with 65 physicians and advanced-practice providers, and two Medical and Wellness Centers, one in Westerly and the other in East Greenwich, with urgent-care facilities and an array of primary-care and specialist physicians.

South County Hospital has long had very high marks for quality and patient satisfaction. Indeed, surveys have often called it the best hospital in its state and one of the best in New England. It was recently awarded a five-star rating by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), putting it in the top 2 percent of those surveyed nationwide.

Louis R. Giancola, the system’s president and chief executive, attributes much of the hospital’s success in patient satisfaction — and fiscal stability — to the strong engagement of its staff, which “we keep in the know’’; a “supportive board’’; the long-term loyalty of people in the service area, and the “nimbleness of a community hospital’’. Having a relatively affluent market with many well-insured people hasn’t hurt either, he acknowledged.


Mr. Giancola.

A particular point of pride is: “We’re good at transitions of care. Maybe that’s a result of our being small.’’

South County Hospital, like virtually all health systems these days, faces many challenges in dealing with the rewards and penalties involved in the forced-march transition to value-based reimbursement. Mr. Giancola notes:

“Medicare incents us to improve patient satisfaction, reduce hospital infections and avoid various patient injuries.  Most commercial payers (insurers) have followed suit. I believe the threat of reduced payments has focused our attention on these measures even though we sometimes complain that the measures are not always fair.’’ (See below.)’’
“It’s all about blocking and tackling. The biggest issue is readmissions within 30 days. {South County has long had lower readmission rates than most hospitals.} We’ve really focused on managing the transition from the hospital to another level of care. The important element is good communication between the hospital providers and the skilled-nursing facility, home health and the doctors caring for the patients in the community.’’

Part of South County’s recognized success in overseeing clinically successful and financially efficient transitions – and, in so doing, reducing costly readmissions — has been its emphasis on using, when possible, home health care instead of nursing centers to save money and improve care, Mr. Giancola said.

The Centers for Medicare & Medicaid Services and other regulators and payers have been pushing hard for better patient-care management, especially since the Affordable Care Act took full effect. Much of South County Health’s work in this area involves helping primary-care physicians to be better traffic managers of their patients’ care.

Another transition success story he cites is medication reconciliation. “Often patients are confused about their drugs and that can lead to readmission because they take drugs that are contra-indicated or they take two meds designed to address the same problem. We’ve hired pharmacists that review meds in the hospital to ensure they are reconciled and the patients get clear advice on discharge.’’

He notes as an example of what might sometimes be unfair pressure from the Feds: CMS’s making hospitals put many patients who have to stay in the hospital for a night or two into “observation’’ status instead of as inpatients, thus slashing potential hospital reimbursement.

Bundled payments, Medicaid and an ACO

An increasingly important strategy for controlling costs and improving care is bundled payments.

South County Health participates in a bundled-payment program for joint-replacement patients with Blue Cross for their Medicare Advantage and commercial-insurance members. (Cambridge Management Group has been doing a lot of work in bundled-payment programs and so this particularly caught our eyes.)

With older-than-average market demographics, the joint-replacement business is a major contributor to the system’s bottom line. (However, while the system is financially stable, its operating margin is only about 2 percent; the system is closely managed.)

Mr. Giancola said that, as with many things in the brave new world of value-based medicine, it’s unclear what sort of savings may come out of the move to bundled payments. However, he thinks that the clinical benefits are clear:

“The bundling process helps us to get a better handle on the clinical process. Having to report quality throughout the entire episode of care makes for better transitions and final outcomes.’’

South County Hospital’s leaders are happy that the Affordable Care Act has put so many uninsured people into Medicaid. While Medicaid reimbursements lag those of Medicare it’s a lot better than no insurance for low-income people. Many of those people, of course, have long used the emergency room as their major source of “free’’ (to them) medical care.

But, perhaps surprisingly, Mr. Giancola told us, Medicaid expansion has not yet cut the flow of people into South County Hospital’s ER, despite efforts encouraged by public and private insurers to promote more and better preventive care to keep people out of the ER. “ERs are too handy for lots of people,’’ he observed.

South County Hospital has had to deal with many other changes, whose long-term fiscal effects are difficult to predict. One is the rising number of employed physicians, hired, Mr. Giancola says, to ensure that the hospital can maintain the range of services that patients want and need in an acute-care facility, such as obstetrics.

Mr. Giancola notes that’s expensive. “Hiring doctors away from private practices to be based in the hospital puts them in more expensive places, with expensive support staffs, equipment and technology. The jury is out on whether the increase in hospital-employed physicians will save money in the long run.’’

Also unknowable at this point is whether South County’s participation in an Accountable Care Organization with Blue Cross & Blue Shield of Rhode Island (BCBSRI) and Integra Community Care Network will ultimately save money. Integra is a partnership of Care New England Health System and its network physicians, Rhode Island Primary Care Physicians Corporation and South County Health and its network physicians. Focused on population-health management, the ACO provides incentives for Integra’s providers to proactively manage patient health, with a heavy emphasis on prevention of illness, while trying to restrain costs.

South County Health, as befits a, well, beloved local institution is big on promoting community-wide collaboration of institutions that can help improve not just healthcare in a clinical sense, but population health.

Toward that end, it has brought together such diverse agencies as the YMCA, the five Federally Qualified Health Centers in its area, school systems, the local Community Action Program and community members to harness the resources of the community. Whatever happens to the ACA, the move toward community and population health will continue, and South County Health will help lead it in southern Rhode Island.

Mr. Giancola has written: “Our long-term goal is to inspire the broader community to see health as a community issue and to mobilize government, schools, businesses and citizens at large to rally around efforts to ensure a healthy community.’’

Dearth of data on bundled payment effects

A Modern Healthcare news analysis finds a dearth of data on the effects of bundled-payment models on  costs and  healthcare quality, a challenge emphasized by the latest government report on Medicare’s voluntary Bundled Payments for Care Improvement (BPCI) initiative.

“In one clinical episode—orthopedic surgery—setting a flat price for all of the care delivered during the episode of care appeared to reduce costs and improve patient outcomes. But for others, there simply wasn’t enough evidence to declare the bundle a success or failure,” the news service concluded.

“It’s hard to draw conclusions either way from this report,” said Dr. Chad Ellimoottil, an assistant professor at the University of Michigan whose research focuses on alternative payment models, including bundled payments.

“The results to me just reinforce what we already know,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, a not-for-profit organization that studies and promotes value-based payment models. “For some of these episodes, like joint replacement, it works fine,” he told Modern Healthcare. “Everything depends on the episode or the condition or the illness you’re looking at.”

Modern Healthcare said that Mr.  de Brantes “was less sanguine about the administration’s full-steam-ahead approach. He questioned several aspects of its bundle design, including that the episodes are triggered by hospitalization rather than encompassing the management of a condition. He also criticized the lack of adjustment for patient severity.”

“Could it be a lot more definitive and improved over time? Of course,” de Brantes said of Medicare’s bundled-payment models. “It’s up to the government to really come to grips with how to design this the right way and how to implement it the right way.”

But Mark Fendrick, a professor at the University of Michigan and director of its Center for Value-Based Insurance Design, said: “The BPCI evaluation adds to the growing body of research that changing provider incentives away from a volume-driven model can produce modest savings without compromising quality of care.”

To read the Modern Healthcare analysis, please hit this link.



In the EHR age, clinician-to-clinician questioning remains essential


“The Conversation (circa 1935), by Arnold Lakhovsky,Marla Durben Hirsch writes in a FierceHealthcare piece that despite all the hoopla about electronic health records and the general digital delirium we’re all in, there’s no substitute for clinicians to have real conversations with each other and patients. With such new advances as bundled payments, this will remain just as important as it has always been.

As an example of the EHR benefits she cited, regarding a Vanderbilt University study:

“The researchers compared a typical process map for a high-risk situation (discharge from a cardiac unit) to the information in an EHR and discovered that the EHR provided more detailed information than the regular process map. For instance, it provided information from sub-processes, such as EHR notes, orders and forms, and identified 12 additional provider types involved in the cardiac unit. Moreover, 35 percent of providers involved in care on the unit were ‘unexpected’ in the process. All of this additional input into the analysis would be helpful in the quality improvement activities and ultimate patient safety efforts.”

She added: “We’ve known for years that the data in EHRs can be used for a multitude of secondary uses, such as research into identifying at-risk patients, determining who would be well suited to participate in clinical trials and the like.

“These new studies point to even more opportunities to harness EHR data in new ways to improve clinical care and patient safety.”

“But why did it take an EHR to unearth some of this information? Why did it take an EHR to determine that there are more providers involved in discharging patients from an inpatient cardio unit than first expected? Why did it take an EHR to uncover that the same providers, whether by specialty, personal relationships, or being scheduled in a hospital at the same time, end up informally working together to coordinate care?”

“Why not simply ask?

  • ‘Hey, are there any other staff members that we should include in our analysis of risks on this cardio unit?’
  • ‘How did that provider end up providing care here?’
  • ‘Are there particular clinicians you seem to end up working with regularly when coordinating care in our hospital? Should we designate the three of you a team to make patient care easier?”’

To read the report from  the Vanderbilt researchers, please hit this link.

To read Ms. Hirsch’s essay, please hit this link.


Creating maternal-care bundled payments is tough


A few hospitals are now using a bundled-payment system like that already used for some orthopedic operations for those on Medicare.

Of course, that model has famously gained popularity among Medicare officials in recent years as the CMS seeks to curb costs while improving outcomes.

Some healthcare experts think that  maternity care may have  perhaps  great bundled-payment potential  But there are only a few pilot programs across the U.S.  And expansion will be complicated.

The biggest obstacle is that because Medicaid is state-federal, unlike Medicare is totally federal, Medicaid can’t force the use of bundled payments as Medicare can. But then establishing bundled payments is intrinsically complicated, although the longterm effect is to simplify treatment and billing by creating orderly, standardized, predictable, evidence-based systems.

Modern Healthcare noted that process design is a big question in setting up maternal bundled-payments systems.

“What should trigger the bundle? Does it begin with prenatal care? With delivery? When should it end, and whom should it include? How should providers—primarily hospitals, but sometimes birth centers—take on financial risk? Some models allow high-risk mothers, such as those who are obese or have AIDS, or high-risk babies; others include only low-risk pregnancies.”

And how do you establish standardized systems? As the publication reports: “{O}ne-off contracts between providers and payers {have} proved tedious and unreliable.”

Modern Healthcare notes that U.S. maternal healthcare is not particularly good when compared to many other nations, and implies that a bundled-payment approach might improve things.”

“Bundling payments may help recalibrate maternity care to focus on what’s best for the mother and child, smooth out these imbalances in costs and make prices more predictable, according to the model’s boosters.”

But it will be a much tougher to get going than Medicare bundled payments, which is being extended into cardiac and other care from orthopedics.

To read the Modern Healthcare piece, please hit this link.

Ex-Cisco exec/new CMG adviser talks about the centrality of bundled payments


CMG chatted with one of its relatively new senior advisers, Reza Mahdavi, the other day. Mr. Mahdavi is a well known international executive, technologist and consultant who has brought to CMG a rich mix of business and applied-technology experience.

He helps to make process analytics and patient-specific data swiftly available and understandable to clients. CMG is integrating Mr. Mahdavi’s experience with existing CMG services to guide client teams launching bundled episodes of health services and further focus on improving clinicians’ effective use of software.

Mr. Mahdavi told us: “We at CMG believe that implementing and refining bundled-care programs {a CMG specialty} will be the main tool for addressing payers’ (especially CMS’s) value-based mandates. ‘’ CMG early on understood the clinical and organizational-economics implications of bundled care, which is now rapidly being expanded from the orthopedic sector, where it started, to such other areas as cardiology.

Mr. Mahdavi is probably best known for his work at Cisco Systems, where, among other duties, he led the company’s sales and service operations in developing nations. In this post, he helped make the Developing World the company’s highest growth region. For three years running he was named Cisco’s vice president of the year.

Mr. Mahdavi said he was drawn to work with Cambridge Management Group, founded back in 1985, because of its “deep knowledge of healthcare’s unique organizational structures and collaborative needs and the emotional intelligence of CMG senior advisers in working with clinicians and healthcare executives. CMG understands the mindsets of people working in healthcare.’’ Given that its staff comprise a mix of people with lengthy clinical and/or executive experience that’s not surprising.

“No organization that I am aware of has such knowledge of the structure and language of healthcare institutions and expertise in facilitating interactions among clinicians and others in healthcare while improving hospitals’ bottom lines.

“CMG has a well-known ability to help get clinicians, famous for their desire for maximum autotomy, to realign their work to address the new organizational and process demands of healthcare reform.

“Healthcare has not been good at creating efficient and cost-effective organizational structures because, in part, clinicians, are used to a great deal of independence.

“And healthcare institutions have tended to mold themselves around the needs and wants of clinicians more than around patients. At Cisco, it was the other way around: We molded our organization around the needs and wants of the customers.’’

But now there’s “‘patient-centered care,’ pushed by payers and patients newly empowered by access to vast amounts of comparative information. Cambridge Management has been in the forefront of this change, armed with its more than three decades of experience in working very closely with hospital executives and clinicians.

“This knowledge helps CMG help institutions meet the demands of new government-mandated value-based reimbursement systems by structuring the most efficient bundled-care systems for improving medical outcomes while ensuring the long-term financial health of hospitals and other healthcare institutions. ‘’

Fixing U.S. health-cost crisis: Bundled payments vs. capitation


In the Harvard Business Review, Michael E. Porter and Robert S. Kaplan argue for bundled payments, writing that it generates the kind of competition among providers that improves the value of healthcare. But in the accompanying piece, Brent C. James, M.D., and Gregory P. Poulsen push for capitated payments, which  they call the only approach  that would encourage healthcare providers to attack all types of waste.

(We at Cambridge Management Group think that the bundled-payments approach works best.)

Professors Porter and Kaplan conclude :

“The time has come to change the way we pay for healthcare, in the United States and around the world. Capitation is not the solution. It entrenches large existing systems, eliminates patient choice, promotes more consolidation, limits competition, and perpetuates the lack of provider accountability for outcomes. It will fail again to drive true innovation in healthcare delivery.”

And, “Much remains to be done to put bundled payments into widespread practice, but the barriers are rapidly being overcome. Bundled payments are the only true value-based payment model for healthcare. The time is now.”

But Dr. James and Mr, Poulsen argue:

The solution to America’s healthcare cost “quandary is to change the way businesses, government, and other purchasers pay for healthcare to population-based payment. Under this approach, providers receive a fixed per person (or ‘capitated’) payment that covers all healthcare services over a defined time period, adjusted for each patient’s expected needs, and are also held accountable for high-quality outcomes. It’s the only payment system that fully aligns providers’ financial incentives with the goal of eliminating all major categories of waste. It fundamentally shifts the role of managing the amount, form, and cost of care from insurers to medical practitioners. It also ensures that providers receive enough of the savings that they can afford to fund the changes needed to bring down costs.”

To read both articles, please hit this link.

Cutting readmissions through bundled-payment systems

revolving door

Here’s an overview of how bundled payments are helping to drive down  hospital readmissions by encouraging  the creation of seamless continuums of care through much stronger care coordination,  the creation of community partnerships and educating patients to take a far more active role in setting and achieving their medical goals.

To read the Health Leaders Media article on this, please hit this link.


Outpatient joint replacements pose big threat to hospitals


In the past, people getting total hop or knee replacements have usually been operated on in a hospital inpatient surgical unit, then they remain a few days in the hospital and finally they are are moved to a skilled-nursing or rehab facility or get home health care.

“{T}hat’s starting to change, and tensions are rising between hospitals and orthopedic surgeons as a result. Building on advances in surgical technique, anesthesia and pain control, a small but growing number of surgeons around the country are moving more of their total joint replacement procedures out of the hospital, performing these lucrative operations in outpatient facilities. Some are sending their patients home within a few hours, while others have their patients recover overnight in the surgery center or hospital during 23-hour stays. These surgeons say very few of their patients require skilled nursing, rehab or home healthcare. ”

The publication then  states what might be obvious:

“Moving these procedures to outpatient settings poses a major threat to hospital finances, since total joint replacements are one of the largest and most profitable service lines at many hospitals….The financial threat will be even greater if the CMS changes its rules and allows Medicare and Medicaid payment for these outpatient procedures, which observers expect will happen in the next few years.”
“The migration of total joint replacements to outpatient settings also raises questions about the future of Medicare’s mandatory bundled-payment initiative for inpatient procedures in 67 markets around the country, called the Comprehensive Care for Joint Replacement program, which began in April. If the CMS decides to pay for ambulatory procedures, that could undercut the hospital bundling initiative.”


MH TAKEAWAYSThe migration of lucrative joint-replacement surgeries to outpatient settings will cause friction between surgeons and hospitals and raises questions about the premise of Medicare’s new bundled-payment initiative for hospital-based procedures.

Critics ask, so what? “Why would we not encourage the migration to outpatient if the outcome is the same and the cost is lower?” said Jeff Goldsmith, a national adviser to Navigant Healthcare. Goldsmith, a Medicare beneficiary, recently underwent a hip replacement and recovered so quickly he thinks it could have been done on an outpatient basis. “Why preserve the (inpatient bundling) program if the whole point is to save money for Medicare?” he said.

Until recently, outpatient total joint replacements were rare. Most providers and patients thought a several-day hospital stay was needed because of the pain, mobility and infection risks associated with these major surgeries. Now, when patients’ health plans allow it, leading surgeons in this field say they are doing many or most of their joint replacements on an outpatient basis—except for patients who are extremely obese or have unstable chronic conditions. They say even healthy patients in their 70s or 80s can be candidates for outpatient surgery, but careful patient selection is essential.

Many more surgeons are eager to learn these improved clinical processes and start doing joint replacements outside the hospital. “Dr. Hoffman has surgeons and administrators from all over the country come tour and watch our processes two or three times a month,” said Michael Patterson, CEO of the Mississippi Valley Surgery Center, who recommends slow, careful adoption of outpatient procedures. “We advise surgeons that first they need to be able to get patients in and out of the hospital within 24 hours. They can’t go straight from three- to five-day stays to 23 hours.”

The emerging outpatient delivery model is driven by both patients’ and payers’ desire to reduce their costs, increase convenience and satisfaction and diminish the risk of hospital-acquired infections. Orthopedic surgeons say doing joint replacements on an outpatient basis cuts costs nearly in half, although reimbursement is also lower. “People want quality at a reduced cost,” said Dr. Patrick Toy, who has done nearly 250 hip and knee replacements at the outpatient Campbell Clinic in Memphis, Tenn., which he partially owns. “This hits the nail on the head.”

Despite the looming financial threat, many hospitals have not settled on a strategy to address the outpatient migration, particularly where local surgeons have not yet adopted this new practice pattern. In some markets, hospitals and surgeons are starting to collaborate, while in others there may be conflict over who will capture the big dollars from joint replacements, which are surging as the baby boomers move into their creakier years.

“This is coming whether we like it or not, and we have to figure out how to better partner with physician practices to deliver the best care for patients and hopefully protect patient volume for the hospital,” said Kyle Armstrong, CEO of Baptist Memorial Hospital-Collierville, a suburb of Memphis served by Toy’s free-standing surgery center. “I can imagine there will be some areas where it is contentious.” His system has considered buying or partnering in a Memphis outpatient surgery center.

In 2014, 23% of 354 hospitals surveyed by the Advisory Board Co. performed at least some outpatient knee replacements, while 7% performed at least some outpatient hip replacements. Experts say those numbers likely have increased in the past two years as more surgeons and their teams gain confidence with new and improved clinical protocols, making it possible to release patients more quickly.

“More hospitals are starting to move joint replacement into outpatient settings to compete with (free-standing) ambulatory surgery centers,” said Shruti Tiwari, a senior consultant at the Advisory Board. “Patients are warming up to the idea, particularly younger and healthier patients who don’t have time for a three-day hospital stay and a protracted recovery process.”

“The smart, strategic hospital management teams understand they need to get ahead of this, so that when volume shifts out of their buildings they won’t lose patients,” said Brian Tanquilut, a senior healthcare analyst at Jefferies & Co. “That’s why the investor-owned hospital companies are making a big push on surgery centers.”

Even at hospitals that are already collaborating with their surgeons on outpatient joint replacements, executives caution that there are problems making outpatient joint replacements financially viable.

“The current ambulatory reimbursement system isn’t really sufficient to cover the overall cost of care,” said Michael Dandorph, chief operating officer at Rush University Medical Center in Chicago. He projects that up to 25% of joint replacements may be done on an outpatient basis within five years if Medicare starts paying for them. “On a single-case basis, we’re taking a revenue hit. But if it produces better outcomes and lowers the cost, that should attract more patients,” he said.

Orthopedic surgeons say that while they would like to collaborate with hospitals on outpatient joint replacements, institutional inertia makes it hard to implement innovative practices that better serve patients.

Dr. Richard Berger performs nearly 800 outpatient total joint replacement procedures a year, split between Rush University Medical Center’s ambulatory surgery unit and the Munster (Ind.) Specialty Surgery Center, a free-standing facility he partially owns. “Even at Rush, which is a great hospital, it’s hard to make changes and try new things,” he said. “At the surgery center, I make one phone call and anything I want to do, I can do.”

“You can control costs so much better in the ambulatory surgery center setting,” said Dr. Alexandra Page, who chairs the American Academy of Orthopaedic Surgeons’ Health Care Systems Committee and whose practice partner has started doing joint replacements in a free-standing outpatient center in San Diego. “That works for everyone but the hospital.”

Some hospitals, such as Rush and CentraCare Health’s St. Cloud (Minn.) Hospital, are responding by working with surgeons to do same-day or

23-hour joint replacement procedures either in hospital-run surgical units or outpatient centers, depending on each patient’s needs. Dr. Joseph Nessler and his colleagues at St. Cloud Orthopedics, a 21-physician independent practice group, are doing more than 300 total joint replacements a year on an outpatient basis, divided between the physician-owned St. Cloud Surgical Center and the hospital. The chosen surgical setting is based on each patient’s medical condition and whether an overnight stay is needed

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