Medicare's new 23 and out for hip and knee replacement?

I have not heard of such a rule. Having gone through a TKR, I would say that going home after 23 hours would be a stretch to say the least. But, after day three in the hospital, I WAS able to stay in my home, alone, with a nurse provided by Medicare changing dressings every day and PT after day 4, I think. It's not optimum, but it is doable. The pain is acute, and needs to be managed and treated aggressively. I would much rather be in my home than in a rehabilitation facility.

@mamie, something about what you were told about hospital care after surgery sounds fishy. Just recently, I read an article on this subject by a medical information service (dated December 27, 2017). There was no mention of a "23 and out" rule (four days before it was to go into effect, according to your surgeon). For several years, there has been a "two midnights" rule, and that's still around for use in some situations. Perhaps you were hearing from your surgeon about rules internal to his/her practice.

For example, is your health care provided by an HMO (health maintenance organization) under Part C, Medicare Advantage? If so, the HMO has plenty of authority to craft some of its own rules to cut down their costs -- or sometimes, to shift costs from Medicare Part A (Hospitals) to Medicare Part B (Doctors), which can work to the advantage of the doctors and the HMO because patients have to cover 20 percent of every dollar charged under Part B, but not under Part A.

Perhaps you or your family could inquire of other officials of your health care provider on whether such a "23 and out" rule is, in fact, in effect, where it came from (a citation from the Code of Federal Regulations, for example), and whether there are exceptions for special circumstances such as yours.

If you get better news from your inquiries, we'd all be grateful to know what it is. Martin

@predictable No, I am on Medicare and pay for a Supplement policy which picks up the extra that Medicare does not pay.

I am finding that a lot of Medicare news is not getting reported by mainstream media.
I Googled for info, for instance, and found an AARP article
https://www.aarp.org/politics-society/advocacy/info-2018/medicare-physical-therapy-caps-fd.html?intcmp=AE-ALRT-POL-MEDICARECAPSVIDEO
about how Congress usually repeals each year an automatic cap on speech, physical, and occupational therapy. But, as of Jan. 24, when the article was written, it had not. I was not aware of this at all. That mean therapies are limited to $2,010. And if Medicare does not pay, supplements also do not pay.

So I am still searching for more info but I can't imagine why the surgeon would make a point of saying it since my sister was just in the joint camp to get some answers and had not signed on with the doctor yet. In addition, I asked questions and I am not signed up with that surgeon for hip replacement.

I will continue searching as well and encourage all to do so. If anyone finds any rules and regs I could read, I would appreciate it.

Thanks, @mamie. Two things about that article. First, the therapies you mentioned are covered under "rehabilitation" rules, which are separate "outside" services ("outside" means not basic hospital or clinic services), and this helps to vastly confuse us in our efforts to understand the Medicare save-some-bucks practices. Second, the article explains that Medicare's automatic waiver of the cap on rehabilitation charges expired on December 31, 2017, and hasn't been renewed by Congress. I think this is mainly because Congress hasn't passed a regular appropriation bill for health programs in Fiscal 2018. That bill is the customary vehicle for making exceptions to program rules and charges.

We're still puzzling about the surgeon's "23 and out" rule. I'm inclined to agree that s/he probably wasn't conniving for a few bucks, but just mistaken (or confused about the "two midnights" rule). But something remains fishy about that, and I'll keep looking for answers.

Thanks, predictable. I now have more clarification. I called the office of the ortho surgeon who made the comments. I got a call back and was told that, as of Jan. 1, Medicare allows outpatient surgery for hip and knee replacements. So, apparently, even if you can go to a hospital and stay overnight, you are an outpatient, not an inpatient.

And, not of Jan. 1 but apparently as part of a gradual change over the last year, Medicare does not allow a patient to stay in the hospital unless "medically necessary." Since "most" people need what is deemed "custodial care" -- trying to walk, doing daily living tasks -- after that surgery, they can not stay in the hospital. But since Medicare requires a 3-night hospital stay for rehab in a nursing home, if you go to such a rehab center now, it is only private pay - YOU pay for it. And who the heck can afford that?

The person said that hospitals instead give you a "plan of care" where you arrange to have family or friends help you out and that you agree to stick to your exercise plan. That's great, I said, but what if you don't have family in the area, your friends have their own medical problems, and your neighbors either work or are elderly. Apparently that's unfortunate for the patient.

So the "23 and out" rule must have been just the doc's catchphrase for what is happening. Apparently our government -- in giving us more "choice" in the matter-- allows outpatient surgery which works to the detriment of those who don't have money for private care or friends or family who can provide any care they need in those first several days or weeks.

I can understand that the government needs to rein in costs but it needs to be reasonable with some common sense in the matter. It should be interesting to see what happens with this penny-wise, pound-foolish idea and people who have blood clots, infections, falls, etc., have to return to the hospital.

Great work, @mamie. A lot of clarification in your report on your inquiries -- and a lot of worry, from my point of view. It's still murky, given the fact that it involves differing rules based on Medicare Part A (hospitals); Medicare Part B (doctors and clinics); in-patient and out-patient surgery; aftercare in hospitals, nursing homes, and rehabilitation programs; all of which can be modified under Medicare Part C (Medicare Advantage) -- so many factors that it seems as though no general rules can apply and every case must be judged on its own set of facts!

What appears to be at work here is removal of Medicare services and support without benefit of Congressional involvement -- in short, unilateral actions by the Executive Branch alone, with virtual (artificial) approval by a Congressional leadership that has failed to even consider (let alone enact) appropriations legislation in which issues such as this are dealt with directly and transparently. Makes me think health care as a right for everybody is the only answer.
Martin

This also gives surgeons the ability to do do more surgeries in a day, maybe 7 surgeries instead of 5 a day. Then they can spend less time between patients cleaning that OR well enough to insure that no one goes home with a staph infection. Not. That's lovely, how many more corners can they cut?

Hi Froggy T,

I heard about this a week before my current TKA. This is my second TKA. I was eating at the hospital cafeteria (inexpensive usually good) with some nurses. I asked them to help me figure out which day to plan on being discharged so that i would not be stranded like last time. Surgery on Thursday, counts as one day, then Friday, then.......nurse says, no count on 23 hours then home. Shockwave. Ok So i ask my surgical team if this is true.

The answer was yes. There are criteria for example, if you are under 75, your BMI is less than 40, you do not have diabetes, you are not on Plavix or other not mentioned drugs, no complications, then yes, 23 hours you are out. I will try to find the research i did on this and get it to you. Running out of time as my computer decided to do updates, now, go figure. My in-home PT will be here shortly. He looked surprised when i said that Medicare covered his services last year. Who knows what will be covered this year. Deductibles and out of pockets are up and some services are only Tier II. Try deciding whether or not to pay $300 up front for the Active Wear Circulation Pump or wait and see if insurance (Medicare does not) will cover it at $459. If they don\'t, you pay $459.

Any way disclaimer: all viewpoints here are the opinions and knowledge of me, Nancy Homeier, and do not reflect the opinions, values, beliefs, knowledge, of my employer, friends, or family.

See you in a bit

Hold on

Nancy

P.S. Both TKAs i have come home to just me and my cat(s).

Hi, @nancylh You are in my thoughts. I hope your recovery goes smoothly.
@predictable - I hope you saw her note as well. So Nancy now has confirmation of what I had mentioned earlier. I had wondered whether it was just the message of one hospital/surgeon in my area but I guess not. People/voters have to be made aware of this!

I have seen nothing on the news and read nothing online. Seniors need to start speaking out to the organizations they belong to so that the erosion of Medicare stops. We need to bolster Medicare for all of the Baby Boomers entering -- not be giving tax breaks to the fabulously wealthy.

Wouldn\'t giving knee/hip replacement patients a better start -- either with an extra day at the hospital or at rehab -- make more sense than expecting people to fend for themselves less than a day after having such major surgery? These cost-saving \"formulas\" need to have more common sense and use fewer stats that allow for \"collateral damage.\" Two friends who had knee replacements a few years ago said the extra day helped get pain under control, got them established into what they had to do, and gave them confidence. And they had a spouse at home to help care for them.

Ok, I guess i\'m not looking under the correct search terms. I\'m not finding a good definition of the criteria. The entire issue is all about the bucks, bout the bucks not the patient.....whoops.....fits the all about the bass song. Sorry. Has to do with payments and inpatient vs. outpatient. This is the kind of stuff i found, i looked at articles by CMS, but they were very very long, did not give a concise definition of the criteria and so my knee will not allow me to sit here any longer. Sorry, i\'ve disappointed you and myself. All i have is what i was told. BMI >40, Diabetes, Taking Plavix etc. (implies heart disease), under 75 years old, can send home at 23 hours. But in the reading i just did, they talk about comorbidities (sp?) and the patient being switched over to inpatient if necessary. It seems to be a very tangled, complicated mess.

All i know is that 23 hours would be a very short time for any surgery, not just major surgery like TJA (total joint arthroplasty). My surgery this time was done by 10 a.m. Thursday. I was discharged by 11 a.m. Saturday. Before lunch. My BMI is 41, i have recently been diagnosed with diabetes 2, i have anxiety, hypertension, am being empirically treated for un-diagnosed congestive heart failure, morbid obesity, and so that is most likely why they kept me that long. The long lasting pain block ended on Friday at which point i did require IV pain meds just to move my leg. I guess that played a part also.

On a lighter note, my PT said i was doing much better than last time, good range of motion. So, keep doing the exercises, walking, keep up with the pain meds (this one is important) which means taking them regularly so the pain doesn\'t exceed what you can handle and also keeping up with the threat of constipation. I have my stock, sugar free candy with Stevia and sorbitol. Sorbitol has a laxative effect. Fiber one bars and Kashi cereal. And of course they have me on Senna - S and i also have Metamucil should i need it.

Being prepared is huge when you go home alone after surgery. One little thing out of place can stop you in your tracks. Like the 45 pound bag of cat litter that came from Chewy and got left next to the mini washer in the kitchen. So, then you have to reach out and try to find someone willing to come push that box out of the way. Oh my.

Anyway, OUCH have to go now. Hope i haven\'t tipped the apple cart.

n
Unlike traditional medical risk stratification for TJA, it is important to evaluate anxiety levels and social support for patients being considered for OTJA. Even patients without diagnosed anxiety disorder are often concerned about postoperative pain, being able to care for themselves, and mobility, especially if they live alone. A study of the effect of psychological support on patients indicated for primary TJA published by Tristano et al. demonstrated that patients who received psychological support had a lower incidence of anxiety and depression than those who did not [10]. Additionally, THA patients who received psychological support reached their physical therapy goals 1.2 days sooner than those who did not receive any psychological support [10]. Patients being considered for OTJA, who are required to manage their own pain control, physical therapy, and self-care, are even more likely to benefit from a strong psychological support. Identifying patients who already have strong social support vs. those who do not is thus extremely beneficial.

A detailed clinical and social assessment such as the General Anxiety Disorder-7 (GAD-7), which is a self-reported questionnaire for screening and measuring general anxiety disorder, is a useful tool and can be used in concert with other tools for screening overall health, such as the revised cardiac risk index (RCRI). For example, a patient may have three identified risk factors:

High body mass index (BMI)
Symptomatic chronic heart failure
Anxiety
These risk factors need to be properly managed and tracked until they are clinically capable of proceeding with surgery. Possible interventions for this patient may be setting up an appointment with a dietician, working with their primary care physician and cardiologist to manage congestive heart failure (CHF), and setting them up with psychotherapy prior to their visit. Risk calculations and historical data tell us the obese patients have higher risk for readmissions and complications [11]. If these issues are not managed, this patient could become one of the “bundle busters,” and experience complications and/or costly readmissions that may have been avoidable with more thorough preoperative optimization.