Recent trends in Medicare utilization and surgeon reimbursement for shoulder arthroplasty

Rate of incidental findings on routine preoperative computed tomography for shoulder arthroplasty

BACKGROUND

Incidental findings are commonly noted in advanced imaging studies. Few data exist regarding the rate of incidental findings on computed tomography (CT) for preoperative shoulder arthroplasty planning. This study aims to identify the incidence of these findings and the rate at which they warrant further work-up to help guide orthopedic surgeons in counseling patients.

METHODS

A retrospective review was performed to identify patients with available preoperative shoulder CT who subsequently underwent shoulder arthroplasty procedures at a single institution between 2015 and 2021. Data including age, sex, and smoking status were obtained. Radiology reports for CTs were reviewed for incidental findings and categorized based on location, tissue type, and/or body system. The rate of incidental findings and the rate at which further follow-up was recommended by the radiologist were determined.

RESULTS

A total of 617 patients was identified. There were 173 incidental findings noted in 146 of these patients (23.7%). Findings ranged from pulmonary (59%), skin/soft tissue (16%), thyroid (13%), vascular (9%), spinal (2%), and abdominal (1%) areas. Of the pulmonary findings, 50% were pulmonary nodules and 47% were granulomatous disease. Overall, the final radiology report recommended further follow-up for 50% of the patients with incidental findings.

CONCLUSIONS

Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. Most of these findings are pulmonary in nature. Overall, half of the patients with incidental findings were recommended for further follow-up. These results establish population data to guide orthopedic surgeons in patient counseling. Level of evidence: III.

Reverse and Anatomic Shoulder Arthroplasty Regional Usage and Open Payment Analysis Using the Centers for Medicare and Medicaid Services Database

Background

This retrospective review aimed to assess if open payments made by industry arthroplasty companies to physicians and hospital systems were significantly affected by implant type and geographic variation.

Methods

Data was obtained from the Centers for Medicare and Medicaid Services (CMS) publicly available open payment datasets (2016-2019). Geographic locations were identified using regions as defined by the US Census Bureau. A linear regression was calculated to predict the open payment made based on the created variable region, the most used implant type (reverse vs anatomic, n > 30 to be included), and their hypothesized interaction.

Results

A significant regression equation was found for the hypothesized interaction between implant and region, F(13,11 186) = 3.446, P < .0001, with an R2 of 0.005. Within the regression, the implant type alone was not significantly related to the open payment (P = .070) but only became significant when paired with the region in the South (US$5807; P < .0001) and West (US$5638; P = .0012) compared to the Northeast.

Discussion

Our multivariate linear regression model revealed that reverse total shoulder implants were associated with higher open payments, but only within the South and West regions. This indicates that the contributions made by industry arthroplasty companies are a function of both implant and region.

Trends in the treatment of proximal humerus fractures from 2010 to 2020

BACKGROUND

The incidence of proximal humerus fractures (PHF) is continuing to rise due to shifts towards a more aged population as well as advancements in surgical treatment options. The purpose of this study is to examine and compare trends in the treatment of PHFs (nonoperative vs. operative; different surgical treatments) across different age groups over the last decade (2010-2020).

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried using International Classification of Diseases and Current Procedural Terminology codes to identify all patients presenting with or undergoing surgery for PHF between 2010 and 2020. Treatment trends, demographics, and insurance information were analyzed during the study period. Comparisons were made between operative and nonoperative trends with respect to the number and type of surgeries performed among 3 age groups: ≤49 years, 50-64 years, and ≥65 years. The rate of postoperative complications and reoperations was evaluated and compared among different surgical treatments for patients with a minimum 1-year postoperative follow-up.

RESULTS

A total of 92,308 patients with a mean age of 67.8 ± 16.8 years were included. Over the last decade, there was no significant increase in the percentage of PHFs treated with surgery. A total of 15,523 PHFs (16.82%) were treated operatively, and these patients, compared with the nonoperative cohort, were younger (64.9 years vs. 68.4 years, P < .001), more likely to be White (80.2% vs. 74.7%, P < .001), and more likely to have private insurance (41.4% vs. 32.0%, P < .001). For patients ≤49 years old, trends in operative treatment have remained stable with internal fixation (IF) as the most used surgical modality. For patients 50-64 years old, we observed a gradual decline in the use of hemiarthroplasty (HA), with a corresponding increase in the use of reverse total shoulder arthroplasty (rTSA), but IF continued to be the most used operative modality. In patients over 65 years, a steep decline in the use of IF and HA was noted during the first half of the decade along with a significant exponential increase in the use of rTSA, which surpassed the use of IF in 2019. Despite the increase in the use of rTSA, no differences in rate of surgical complications were noted between rTSA and IF (χ2 = 0.245, P = .621) or reoperations (χ2 = 0.112, P = .730).

CONCLUSION

Nonsurgical treatment remains the mainstay treatment of PHFs. Although there is no increase in the prevalence of operative treatment in patients ≥50 years in the last decade, there is an exponential increase in the use of rTSA with a corresponding decrease in HA and IF, a trend more substantial in patients ≥65 years compared with patients between 50 and 64 years.

Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution

BACKGROUND

Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA.

RESULTS

Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001).

CONCLUSION

The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

Retrospective analysis shows the cost of Mohs surgery decreases when adjusted for medical inflation

BACKGROUND

Mohs surgery (MS) is the gold standard for treating nonmelanoma skin cancers in cosmetically sensitive areas.

OBJECTIVE

To investigate MS costs over time when adjusting for medical inflation while considering the perspective of patients, payers, and health care systems.

METHODS

A retrospective claim analysis using data from the International Business Machines MarketScan Commercial Claims and Encounters Database from 2007 through 2019 was performed. A query of the database for any instance of a MS-specific Current Procedural Terminology (CPT) code in adults (17311, 17312, 17313, 17314, and 17315) was conducted. Aggregate data per claim regarding coinsurance, total cost, deductible, copay, and insurance payout were provided for each CPT code annually.

RESULTS

The total adjusted cost per claim decreased significantly (P < .001) for 4 of the 5 MS-specific CPT codes between 2007 and 2019: 17311 (-25%), 17312 (-15%), 17313 (-25%), and 17314 (-18%). The patient's adjusted out-of-pocket expense increased significantly (P < .0001) for 4 of the 5 MS-specific CPT codes: 17311 (33%), 17312 (45%), 17313 (34%), and 17314 (43%).

CONCLUSION

Among the 4 most used MS-specific CPT codes (17311, 17312, 17313, and 17314), the total cost per claim decreased and the patient's out-of-pocket expense increased from 2007 to 2019.

Comparison of trends of inpatient charges among primary and revision shoulder arthroplasty over a decade: a regional database study

Background

This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade.

Methods

The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers.

Results

During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%.

Conclusion

Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Professional Fees for U.S. Hospital Care, 2016-2020

BACKGROUND

The latest comprehensive diagnosis-specific estimates of hospital professional fees relative to facility fees are from 2004 to 2012.

OBJECTIVE

Update professional fee ratio (PFR) estimates to improve cost analysis opportunities with hospital discharge data sources and compare them with previous PFR estimates.

SUBJECTS

2016-2020 MarketScan inpatient admissions and emergency department (ED) treat and release claims.

MEASURES

PFR was calculated as total admission or ED visit payment divided by facility-only payment. This measure can be multiplied by hospital facility costs to yield a total cost estimate.

RESEARCH DESIGN

Generalized linear regression models controlling for selected patient and service characteristics were used to calculate adjusted mean PFR per admission or ED visit by health payer type (commercial or Medicaid) and by selected diagnostic categories representing all clinical diagnoses (Major Diagnostic Category, Diagnostic Related Group, and Clinical Classification Software Revised).

RESULTS

Mean 2016-2020 PFR was 1.224 for admissions with commercial payers (n = 6.7 million admissions) and 1.178 for Medicaid (n = 4.2 million), indicating professional payments on average increased total payments by 22.4% and 17.8%, respectively, above facility-only payments. This is a 9% and 3% decline in PFR, respectively, compared with 2004 estimates. PFR for ED visits during 2016-2020 was 1.283 for commercial payers (n = 22.2 million visits) and 1.415 for Medicaid (n = 17.7 million). This is a 12% and 5% decline in PFR, respectively, compared with 2004 estimates.

CONCLUSIONS

Professional fees comprise a declining proportion of hospital-based care costs. Adjustments for professional fees are recommended when hospital facility-only financial data are used to estimate hospital care costs.

Distressed communities demonstrate increased readmission and health care utilization following shoulder arthroplasty

BACKGROUND

Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty.

METHODS

A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits.

RESULTS

Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities.

CONCLUSIONS

Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike.

Utilization of comorbidity indices to predict discharge destination and complications following total shoulder arthroplasty

Background

Comorbidity indices can help identify patients at risk for postoperative complications. Purpose of this study was to compare different comorbidity indices to predict discharge destination and complications after shoulder arthroplasty.

Methods

Retrospective review of institutional shoulder arthroplasty database of primary anatomic (TSA) and reverse (RSA) shoulder arthroplasties. Patient demographic information was collected in order to calculate Modified Frailty Index (mFI-5), Charlson Comorbidity Index (CCI), age adjusted CCI (age-CCI), and American Society of Anesthesiologists physical status classification system (ASA). Statistical analysis performed to analyze length of stay (LOS), discharge destination, and 90-day complications.

Results

There were 1365 patients included with 672 TSA and 693 RSA patients. RSA patients were older and had higher CCI, age adjusted CCI, ASA, and mFI-5 (p < 0.001). RSA patients had longer lengths of stay (LOS), more likely to have an adverse discharge (p < 0.001), and higher reoperation rate (p = 0.003). Age-CCI was most predictive of adverse discharge (AUC 0.721, 95% CI 0.704-0.768).

Discussion

Patients undergoing RSA had more medical comorbidities, experienced greater LOS, higher reoperation rate, and were more likely to have an adverse discharge. Age-CCI had the best ability to predict which patients were likely to require higher-level discharge planning.

Effects of Patient Comorbidities and Demographics on Episode-of-Care Costs Following Total Shoulder Arthroplasty

BACKGROUND

As demand for shoulder arthroplasty grows, adequate cost containment is of importance. Given the historical use of bundle payments for lower extremity arthroplasty, it is reasonable to anticipate that such programs will be universally implemented in shoulder arthroplasty. This project evaluates how patient demographics, medical comorbidities, and surgical variables affect episode-of-care costs in an effort to ensure accurate reimbursement scales and equitable access to care.

METHODS

Consecutive series of primary total shoulder arthroplasty (anatomic and reverse) procedures were retrospectively reviewed at a single academic institution from 2014 to 2020 using claims cost data from Medicare and a private insurer. Patient demographics, comorbidities, and clinical outcomes were collected. A stepwise multivariate regression was performed to determine the independent effect of comorbidities and demographics on 90-day episode-of-care costs.

RESULTS

Overall, 1,452 shoulder arthroplasty patients were identified (1,402 Medicare and 50 private payer patients). The mean 90-day cost for Medicare and private payers was $25,822 and $31,055, respectively. Among Medicare patients, dementia ($3,407, P = 0.003), history of stroke ($3,182, P = 0.005), chronic pulmonary disease ($1,958, P = 0.007), anemia ($1,772, P = 0.039), and heart disease ($1,699, P = 0.014) were associated with significantly increased costs. Demographics that significantly increased costs included advanced age ($199 per year in age, P < 0.001) and elevated body mass index ($183 per point, P < 0.001). Among private payers, hyperlipidemia ($6,254, P = 0.031) and advanced age ($713 per year, P < 0.001) were associated with an increase in total costs.

CONCLUSION

Providers should be aware that certain demographic variables and comorbidities (history of stroke, dementia, chronic pulmonary disease, anemia, heart disease, advanced age, and elevated body mass index) are associated with an increase in total costs following primary shoulder arthroplasty. Further study is required to determine whether bundled payment target costs should be adjusted to better compensate for specific comorbidities.

LEVEL OF EVIDENCE

Level IV case series.

Inflation-Adjusted Medicare Reimbursement for Hip Arthroscopy Fell by 21.1% on Average Between 2011 and 2022

Purpose

To examine Medicare reimbursement for hip arthroscopy from 2011 to 2022.

Methods

The seven most common procedures performed with hip arthroscopy by a single surgeon were gathered. The Physician Fee Schedule Look-Up Tool was utilized to access financial data of the associated Current Procedural Terminology (CPT) codes. The reimbursement data for each CPT were gathered from the Physician Fee Schedule Look-Up Tool. With the consumer price index database and inflation calculator, reimbursement values were adjusted for inflation to 2022 U.S. dollars.

Results

Following an adjustment for inflation, it was found that reimbursement rate for hip arthroscopy procedures on average was 21.1% lower between 2011 and 2022. The average reimbursement per CPT code for the included codes was $899.21 in 2022 compared to inflation adjusted $1,141.45 in 2011, a difference of $242.24.

Conclusions

From 2011 to 2022, the average inflation-adjusted Medicare reimbursement has steadily declined for the most common hip arthroscopy procedures. As Medicare is one of the largest insurance payers, these results have substantial financial and clinical implications for orthopaedic surgeons, policy makers, and patients.

Level of Evidence

Level IV, economic analysis.

Impact of the COVID-19 pandemic on shoulder arthroplasty: surgical trends and postoperative care pathway analysis

BACKGROUND

COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, posthospital disposition, and 30-day readmission rates.

METHODS

This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (Diagnosis-Related Group code 483, Current Procedural Terminology code 23472) from January 1, 2019, to December 18, 2020. Fracture cases were separated from nonfracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. nonwhite), Centers for Medicare & Medicaid Services Hierarchical Condition Category risk score, month fixed effects, and Core-Based Statistical Area fixed effects, with standard errors clustered at the provider level, was calculated using a multivariate analysis (P < .05).

RESULTS

A total of 49,412 and 41,554 total shoulder arthroplasty (TSA) cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in reverse shoulder arthroplasty, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, P < .001) when adjusted for confounders. There was a 5% increase in the discharged-home rate (88.0% to 92.7%, P < .001), which was most prominent in fracture cases, with a 20% increase in discharged-home cases (65.0% to 73.4%, P < .001). There was no significant change in 30-day hospital readmission rates overall (P = .20) or when broken down by individual procedures.

CONCLUSIONS

There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift toward an outpatient surgical model can be performed safely and efficiently and has the potential to provide value.

Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy

BACKGROUND

Cuff tear arthropathy (CTA) can be successfully treated with various types of shoulder arthroplasty. While reverse total shoulder arthroplasty (RSA) is commonly used to treat CTA, CTA hemiarthroplasty (CTA-H, hemiarthroplasty with an extended humeral articular surface) can also be effective in patients with preserved glenohumeral elevation and an intact coracoacromial (CA) arch. As the value of arthroplasty is being increasingly scrutinized, cost containment has become a priority. The objective of this study was to assess hospitalization costs and improvements in joint-specific measures and health-related quality of life for these two types of shoulder arthroplasty in the management of CTA.

METHODS

Seventy-two patients (39 CTA-H and 33 RSA) were treated during the study time period using different selection criteria for each of the two procedures: CTA-H was selected in patients with retained active elevation, an intact CA arch, and an intact subscapularis, while RSA was selected in patients with pseudoparalysis or glenohumeral instability. The Simple Shoulder Test (SST) was used as a joint-specific patient-reported outcome measure. Improvement in quality-adjusted life years was measured using the Short Form 36. Costs associated with inpatient care were collected from hospital financial records. Univariate and multivariate analyses focused on determining predictors of hospitalization costs and improvements in patient-reported outcomes.

RESULTS

Significant improvements in SST and Short Form 36 physical component scores were seen in both groups. Inpatient hospitalization costs were significantly higher in the RSA group than that in the CTA-H group ($15,074 ± $1614 vs. $10,389 ± $1948, P < .001), driven primarily by supplies including the cost of the prosthesis ($9005 ± $2521 vs. $4715 ± $2091, P < .001). The diagnosis of diabetes was an independent predictor of higher inpatient hospitalization costs for both groups. There were no independent predictors for quality-adjusted life year improvements. SST improvement in the CTA-H group was significantly higher in patients with lower preoperative SST scores.

CONCLUSION

Using a standard algorithm of CTA-H for shoulders with retained active elevation and an intact CA arch and RSA for poor active elevation or glenohumeral instability, both procedures led to significant improvements in health-related quality of life and joint-specific measures. Costs were significantly lower for patients meeting the selection criteria for CTA-H. Further value analytics are needed to compare the relative cost effectiveness of RSA and CTA-H for patients with CTA having retained active elevation, intact CA arch, and intact subscapularis.

Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning

BACKGROUND

Given the increase in demand in treatment of glenohumeral arthritis with anatomic total (aTSA) and reverse shoulder arthroplasty (RTSA), it is imperative to improve quality of patient care while controlling costs as private and federal insurers continue its gradual transition toward bundled payment models. Big data analytics with machine learning shows promise in predicting health care costs. This is significant as cost prediction may help control cost by enabling health care systems to appropriately allocate resources that help mitigate the cause of increased cost.

METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018. The database was queried for all primary aTSA and RTSA by International Classification of Diseases, Tenth Revision (ICD-10) procedure codes: 0RRJ0JZ and 0RRK0JZ for aTSA and 0RRK00Z and 0RRJ00Z for RTSA. Procedures were categorized by diagnoses: osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), fracture, and rotator cuff arthropathy (RCA). Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics were included, such as volume of procedures performed by the respective hospital for the calendar year and wage index, which represents the relative average hospital wage for the respective geographic area. Unplanned readmissions within 90 days were calculated using unique patient identifiers, and cost of readmissions was added to the total admission cost to represent the short-term perioperative health care cost. Machine learning algorithms were used to predict patients with immediate postoperative admission costs greater than 1 standard deviation from the mean, and readmissions.

RESULTS

A total of 49,354 patients were isolated for analysis, with an average patient age of 69.9 ± 9.6 years. The average perioperative cost of care was $18,843 ± $10,165. In total, there were 4279 all-cause readmissions, resulting in an average cost of $13,871.00 ± $14,301.06 per readmission. Wage index, hospital volume, patient age, readmissions, and diagnosis-related group severity were the factors most correlated with the total cost of care. The logistic regression and random forest algorithms were equivalent in predicting the total cost of care (area under the receiver operating characteristic curve = 0.83).

CONCLUSION

After shoulder arthroplasty, there is significant variability in cumulative hospital costs, and this is largely affected by readmissions. Hospital characteristics, such as geographic area and volume, are key determinants of overall health care cost. When accounting for this, machine learning algorithms may predict cases with high likelihood of increased resource utilization and/or readmission.

Trends in Revenue, Cost, and Contribution Margin for Total Joint Arthroplasty 2011-2021

BACKGROUND

Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA.

METHODS

We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models.

RESULTS

Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA.

CONCLUSION

Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed.

LEVEL III EVIDENCE

Retrospective Cohort Study.

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty

INTRODUCTION

This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care.

METHODS

Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty.

RESULTS

Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.

DISCUSSION

Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.

Cost comparison and complication profiles of superior capsular reconstruction, lower trapezius transfer, and reverse shoulder arthroplasty for irreparable rotator cuff tears

BACKGROUND

Irreparable rotator cuff tears (IRCTs) pose treatment challenges both clinically and financially. As cost-effectiveness initiatives are prioritized, value-based health care delivery models are becoming increasingly common. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 common surgical treatment options for IRCTs: superior capsular reconstruction (SCR), arthroscopically assisted lower trapezius tendon transfer (LTTT), and reverse shoulder arthroplasty (RSA).

METHODS

Between 2018 and 2020, 155 patients who underwent shoulder surgery at a single institution for IRCT with minimal to no arthritis were identified. Procedures performed included 20 SCRs, 47 LTTTs, and 88 RSAs. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

RESULTS

Mean standardized costs were as follows: preoperative evaluation SCR $507, LTTT $507, and RSA $730; index surgical hospitalization SCR $19,675, LTTT $15,722, and RSA $16,077; and postoperative care SCR $655, LTTT $686, and RSA $404. Significant differences were observed in the index surgical costs (P < .001), with SCR incurring an additional average cost of $3953 and $3598 compared with LTTT and RSA, respectively. The 90-day complication, reoperation, and readmission rates were 0%, 0%, and 0% in the SCR group; 2.1%, 0%, and 0% in the LTTT group; and 3.4%, 0%, and 1.1% in the RSA group, respectively. With the numbers available, differences among the 3 surgical procedures with respect to complication (P = .223), reoperation (P = .999), and readmission rates (P = .568) did not reach statistical significance.

CONCLUSIONS

The mean standardized costs for the treatment of 3 common IRCT procedures inclusive of 60-day workup and 90-day postoperative recovery were $16,915, $17,210, and $20,837 for LTTT, RSA (average added cost $295), and SCR (average added cost $3922), respectively. This information may provide surgeons and institutions with cost-related information that will become increasingly relevant with the expansion of value-based surgical reimbursements.

Inflation-Adjusted Medicare Reimbursement Has Decreased for Orthopaedic Sports Medicine Procedures: Analysis From 2000 to 2020

Background:

Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field.

Purpose/Hypothesis:

The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period.

Study Design:

Economic decision and analysis; Level of evidence, 4.

Methods:

The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test.

Results:

Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = –2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = –2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = –1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = –2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = –2.5%; R 2 = 0.79).

Conclusion:

Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle–related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.

Trends in outpatient versus inpatient total shoulder arthroplasty over time

Background

The purpose of this study was to investigate the safety of outpatient and inpatient total shoulder arthroplasty (TSA) and to investigate changes over time.

Methods

Patients undergoing primary TSA during 2006-2019 as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Patients were divided into an early cohort (2006-2016, 12,401 patients) and a late cohort (2017-2019, 12,845 patients). Outpatient procedures were defined as those discharged on the day of surgery. Patient comorbidities and rate of adverse events within 30 days postoperatively were compared with adjustment for baseline characteristics using standard multivariate regression.

Results

There was a significant reduction in complications over time when considering all cases (5.69% in the early cohort vs. 3.67% in the late cohort, adjusted relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.58-0.73, P < .001). The rate of complications decreased over time among inpatients (5.80% vs. 3.90%, adjusted RR = 0.68, 95% CI = 0.60-0.76, P < .001). However, there was no difference in the rate of complications among outpatients over time (1.98% vs. 1.38%, adjusted RR = 0.64, 95% CI = 0.28-1.47, P = .293). There were significantly more complications among inpatients vs. outpatients in both the early and late cohorts (early: 5.80% vs. 1.98%, adjusted RR = 2.57, 95% CI = 1.24-5.34, P = .011, late: 3.90% vs. 1.38%, adjusted RR = 2.28, 95% CI = 1.39-3.74, P = .001). TSA became more common in elderly patients over 70 years of age over time in both the inpatient and outpatient cohorts, whereas fewer young patients (aged 18-59 years) underwent TSA in the late cohorts than in the early cohorts for both the inpatient and outpatient samples (P < .001).

Conclusion

The overall complication rate of TSA has decreased over time as outpatient TSA has become increasingly common. When contemporary data are examined, the complication rate of outpatient procedures has remained constant over time while that of inpatient procedures decreased, despite the changing demographics of patients undergoing TSA. This indicates that outpatient TSA remains a safe procedure as patient selection criteria have evolved, while the safety of inpatient TSA continues to improve.

Comprehensive Analysis of Trends in Medicare Utilization and Reimbursement in Physical Medicine & Rehabilitation: 2012 to 2017

INTRODUCTION

There is an absence of literature describing Medicare utilization by physiatrists, despite their key role in treating Medicare enrollees with qualifying disabilities and common neuromusculoskeletal conditions.

OBJECTIVE

Analyze Medicare data regarding physiatrists and their beneficiaries, services, and reimbursement, as well as trends in utilization and geographic distribution.

DESIGN AND SETTING

Retrospective analysis of publicly available Center for Medicare & Medicaid Services data for Medicare beneficiaries receiving physiatric services from 2012-2017.

MAIN OUTCOME MEASURES

After adjustment for inflation, variables assessed for changes over time included provider and beneficiary demographics, total Medicare reimbursement, and number of services provided, subsequently separated by drug and medical service metrics. Lorenz curves and Gini coefficients were computed to study reimbursement inequality. Choropleth maps were generated to assess geographic differences in physician density and reimbursement, both by state and ZIP code.

RESULTS

The number of physiatrists utilizing Medicare increased from 7230 to 7895 from 2012-2017, while the average number of unique beneficiaries per clinician remained constant (307 vs 310; P = 0.51). Beneficiaries' mean hierarchical conditions category (HCC) health risk score, normalized to 1.0 for the average beneficiary, increased significantly from 2012-2017 (1.72 vs 1.80; P < 0.01). Mean Medicare reimbursement per physiatrist decreased significantly from 2012-2017 ($131 960 vs $117 623; P < 0.001), while mean number of services remained constant (3243 vs 3077; P = 0.132). Botulinum toxin and baclofen injections were the two most reimbursed drug-related services. Gini coefficients ranged from 0.52-0.53 for 2012-2017, suggesting moderate reimbursement inequality, with the 75th percentile receiving on average 2 times the median. Both physician density and top earners were concentrated in urban and metropolitan areas.

CONCLUSIONS

Despite rising healthcare costs and increasing medical complexity of physiatrists' beneficiaries, Medicare payments have decreased over time. These trends are relevant to both providers and policy makers, particularly in light of unequal geographic distribution of physiatrists across the country. This article is protected by copyright. All rights reserved.

Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019

BACKGROUND

Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures.

METHODS

The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement.

RESULTS

Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001).

CONCLUSIONS

Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Temporal Analysis of Medicare Physician Reimbursement and Procedural Volume for all Hip and Knee Arthroplasty Procedures Billed to Medicare Part B From 2000 to 2019

BACKGROUND

The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000.

METHODS

The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type.

RESULTS

From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019.

CONCLUSION

This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward.