In a world of tightening reimbursements and evolving payment models, it’s not often that the Centers for Medicare and Medicaid Services (CMS) opts to increase payments for a procedure. But that is exactly what happened on Aug. 14, 2017 when CMS published its final rule updating its Inpatient Prospective Payment System to raise the reimbursement bundle for primary and revision total ankle replacement (TAR) procedures. This was a result of advocacy efforts from members of the American Orthopaedic Foot & Ankle Society, the American Association of Orthopaedic Surgery – Office of Government Affairs, as well as Wright Medical and Stryker.
The change took effect on Oct. 1, 2017 and shifts TAR from the Medicare severity diagnosis-related group (MS-DRG) category that included the high-volume procedures of total hip and total knee replacement, into a separate Medicare group that more accurately compensates hospitals for the costs of performing these procedures. TAR procedures are more complex and involve greater resources, including longer operative times and the potential for additional work, such as ligament repair, that is uncommon in hip and knee replacements.
This removes a barrier for hospitals that may have refrained from incorporating TAR into their orthopedic service line because of the lower reimbursement rates. The change will hopefully help surgeons and physicians make decisions around TAR that are based on the best clinical path forward for their patient given the increase in Medicare reimbursement for this procedure. This matters in the midst of a healthcare environment that is weighing the experience of patients more heavily.
From a sheer numbers perspective, there are many fewer patients requiring surgical treatment for ankle arthritis than for hip and knee arthritis. However, of those patients with end-stage ankle arthritis, many more are being treated with a TAR instead of an ankle fusion in 2017 than in years past.
With an ankle fusion, the patient undergoes a surgical operation where screws or plates are used to join or “fuse” the bones of the tibia and the talus in order to create a solid and immobilize the ankle joint with the goal to alleviate pain, correct deformity and thereby improve function. While a good option for pain relief, ankle fusion reduces joint range of motion and can therefore impact the ability of patients to do certain activities and contributes to the development of arthritis at the other joints of the foot, that could further reduce a patients’ quality of life post-surgery.
Patients who receive TAR undergo a surgical operation where ankle replacement implants are used to resurface the ends of the tibia and talus that have been damaged from ankle arthritis, with the intent to help alleviate pain and maintain mobility in the ankle joint. This can lead to a potentially higher level of function and better quality of life for a patient; however, studies are still needed to better understand the improvements that can be gained by ankle replacement over ankle fusion.
The ability to offer a motion sparing ankle surgery, especially for patients who have already had surgery or injury that has stiffened the foot, has been a major improvement in what surgeons can provide to their patients with ankle arthritis. There is no single “gold standard” for the surgical treatment of ankle arthritis because both ankle fusion and ankle replacement have important roles to play in the treatment of ankle arthritis. However, there continues to be significant improvements in implant design features as well as the techniques and instruments to insert total ankles, which will only expand the indications for TAR to a greater range of ankle arthritis patients with the goal of improving health outcomes, which, after all, is the goal of all of us working in healthcare.
Jeffrey E. Johnson, MD is the immediate past president of the American Orthopaedic Foot and Ankle Society (AOFAS.org) and is a professor of orthopaedic surgery at Washington University School of Medicine– St Louis.