Medicare Reimbursement for Total Joint Arthroplasty: The Driving Forces

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.

Impact of a Dedicated Orthopaedic Trauma Room on Elective Arthroplasty Case Volume

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on elective arthroplasty volume.

DESIGN

Retrospective cohort study.

SETTING

Level I academic trauma center.

INTERVENTION

A retrospective analysis was performed for two 3-year intervals before and after DOTR introduction on January 20, 2013, at a Level I trauma center. Surgeons were included if they performed elective primary total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) regularly from 2010 to 2015.

MAIN OUTCOME MEASURES

Change in elective arthroplasty volume after the implementation of a DOTR.

RESULTS

A total of 2339 cases were performed by surgeons A-E, with an average of 303.3 cases per year pre-DOTR and an average of 476.3 cases per year post-DOTR. On average, within our institution, there were 75.79 per 10,000 cases/year in Michigan pre-DOTR and 104.2 per 10,000 cases/year in Michigan post-DOTR. Surgeons A-E averaged 173.0 more cases per year and increased their average proportion of elective arthroplasty case volume in Michigan. There was a statistically significant market share increase of 9.8 per 10,000 cases/year in Michigan, at our hospital in the post-DOTR periods ( P = 0.039) (CI [0.5442, 19.21], SE = 4.523). This market share increase of 9.8 cases/10,000 cases was the yearly increase in market share that our average surgeons saw after the DOTR implementation, this took into account the observed annual increase in arthroplasty volume statewide during those years.

CONCLUSION

Implementation of a DOTR was associated with increases in the total number, annual mean, and annual proportion of elective arthroplasty cases performed in Michigan for both elective surgeons and the institution as a whole. These findings reveal a benefit of DOTR implementation to elective arthroplasty surgeons and health systems on a larger scale, in the form of increased arthroplasty case volume.

Less Than One-third of Hospitals Provide Compliant Price Transparency Information for Total Joint Arthroplasty Procedures

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) recently implemented price transparency legislation. As total joint arthroplasty (TJA) procedures are widely used, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures are a proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, cost estimates for TJA procedures represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population.

QUESTIONS/PURPOSES

We asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes?

METHODS

Our cross-sectional retrospective analysis used the CMS's Hospital Compare database. This database includes information for 5326 Medicare hospitals nationally. We excluded children's, psychiatric, Veterans Affairs, and active military base hospitals as well as hospitals performing fewer than 100 TJAs annually. A total of 1719 hospitals remained after this selection process. Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 facilities for our final analysis. Included hospitals were located predominately in urban areas (79% [317 of 400]) and were mostly medium-sized facilities (43% [171 of 400]). Most hospitals were classified as acute care (98% [392 of 400]) versus critical access. Three reviewers thoroughly searched each hospital website for a machine-readable file providing the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals with any gross price information pseudocompliant. The consumer-friendliness of the website was assessed based on the following criteria: (1) languages other than English were offered, (2) it took less than 15 minutes to locate pricing information, (3) a phone number or email address was provided for questions, and (4) there was a description of procedure in common terms. Pricing information was recorded and compared for CPT codes 27447 and 27130 and DRG codes 469 and 470. Data were sourced from December 1 through 20, 2021, to assess compliance in the first year since the legislation was implemented.

RESULTS

Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing. When segregating by individual procedures, 21% (84 of 400), 18% (72 of 400), 18% (71 of 400), and 19% (74 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130 and DRG codes 469 and 470, respectively. For each code, rates of pseudocompliance were 36% (143 of 400), 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400) for the included codes, respectively. Most included hospitals provided at least some of their pricing data in a user-friendly format. Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code.

CONCLUSION

Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures.

CLINICAL RELEVANCE

Given the potential influence compliance and price sharing may have on empowering patients' healthcare decisions and reducing healthcare expenditures, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available to their patients. In addition to ensuring that all six CMS mandates are met, this should include providing information in easy-to-understand formats and making related services identifiable across all levels of health literacy. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest.

Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299-7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.

Dermatomyositis and polymyositis in total hip arthroplasty

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are systemic autoimmune disorders such as dermatomyositis (DM), polymyositis (PM), inclusion body myopathy, and autoimmune necrotizing myopathy that, similar to osteoarthritis, affect quality of life and activities of daily living. Moreover, these patients are often burdened with chronic pain and disability; however, the outcomes and risk of total hip arthroplasty (THA) in this patient population remain unclear.

AIM

To evaluate 90-d complications and costs in patients with these conditions.

METHODS

A retrospective case control study was designed by accessing data from the Medicare dataset available on the PearlDiver server. Patients with IIM, here, those with DM and PM were matched based on possible confounding variables to a cohort without these diseases and with the same 10-year risk of mortality as defined by the Charlson Comorbidity Index Score (CCI). Univariate and multivariate analysis were performed to evaluate complications and t-tests to evaluate 90-d Medicare reimbursements as markers of costs after THA.

RESULTS

The total sample was 1090 patients with each cohort comprised of 545. Females were 74.9% of the population. The mean CCI was 5.89 (SD 2.11). Those with IIM had increased rates of pneumonia [odds ratio (OR) 1.45, P < 0.001] and pulmonary embolism (OR 1.46, P = 0.035) and decreased hematoma risks (OR 0.58, P = 0.00). 90-d costs were on average $1411 greater for those with IIM yet not significantly different (P = 0.034).

CONCLUSION

Patients with IIM have an increased 90-d rate of pneumonia and pulmonary embolism concomitant with a decreased hematoma rate consistent with their pro-coagulatory state. Further attention to increased resource utilization in these patients is also warranted.

Differences in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores for a Single Surgeon Comparing Two Institutions: An Unfair Reimbursement Metric

BACKGROUND

Emphasis on value-based purchasing links physician financial remuneration to patient-derived outcome scores. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys aim to provide a uniform comparison tool. Of the 22 different survey questions, only 3 (13.6%) focus on experience related to doctors. We sought to determine how HCAHPS scores differ for a single surgeon performing more than 500 total joint arthroplasties annually, divided almost equally between two centers.

METHODS

HCAHPS data from 2015 to 2018 for a single, fellowship-trained arthroplasty surgeon were collected from two different hospitals. More than 200 cases were performed at each center with the same staff. One center is a large metropolitan academic-teaching hospital, and the other is a suburban private hospital. The purpose of the study was to determine if differences existed regarding HCHAPS scores between the two institutions.

RESULTS

A significant difference was found between institutions regarding questions pertaining to "hospital environment," "admission process," and "hospital staff concern for pain," with more patients responding favorably in Institution Two than Institution One.

CONCLUSION

Patient perceptions and ratings of overall experience differ significantly between hospitals even when surgery is performed by a single surgeon. These results lend credence to the fact that surgeons should not be unduly penalized for the hospital in which they operate, and financial remuneration involving HCAHPS scores must be approached with caution. This unfair system could potentially drive surgeons to perform the majority of their cases in the hospital system with higher scores in the nonphysician related domains as this would affect overall patient satisfaction, and thus, financial compensation.

Medicare Total Knee Arthroplasty Patients Need Not Stay 2 Midnights for Full Facility Reimbursement

BACKGROUND

Health care systems are concerned that facility reimbursements will be reduced based on patient length of stay (LOS) of <2 midnights with the removal of total knee arthroplasty (TKA) from the inpatient-only list. The purpose of this study was to evaluate the effect of LOS and postdischarge disposition on facility reimbursement.

METHODS

We evaluated a consecutive series of 470 primary Medicare TKA patients performed at a single institution from 2018 to 2019. We analyzed facility reimbursement based on patient LOS and discharge disposition. Descriptive statistics were analyzed using chi-square test, analysis of variance, and Student t test calculations.

RESULTS

Overall, the facility was fully reimbursed in 401 patients (85%) at a mean of $11,169. The facility received full reimbursement for 323 of 326 (99%) patients with an LOS of <2 midnights who were discharged to home at a mean of $11,156. This reimbursement was significantly (P < .001) higher than patients who had an LOS <2 midnights who were discharged with home health (mean, $9773) or to a facility (mean, $10,095). For those with LOS >2 midnights, there was no difference in mean reimbursement among discharge dispositions ($11,202 vs $11,249 vs $11,085, P = .65).

CONCLUSION

In this study, Medicare TKA patients with LOS <2 midnights were fully reimbursed 99% of the time as an inpatient as long as they are discharged to home without home health or to a rehabilitation facility. Those discharged before 2 midnights who require home health service or inpatient facility are more likely to be reimbursed at a lower penalized rate.

Single Use Instruments for Implanting a Contemporary Total Knee Arthroplasty System Are Accurate, Efficient, and Safe

BACKGROUND

Single use instruments (SUI) is a potential mechanism to improve efficiency and reduce cost in total knee arthroplasty (TKA). New technology requires patient safety and surgical accuracy. A multi-center study of SUI vs reusable mechanical instrumentation (RUI) for a TKA system compared implant placement accuracy and operating room (OR) efficiency.

METHODS

Four surgeons implanted 88 primary TKAs, N = 44 RUI and N = 44 SUI. Accuracy was measured radiographically at 3 months. The primary endpoint was non-inferiority of absolute value of mechanical axis alignment. Radiographic endpoints, OR times, and adverse events were also evaluated.

RESULTS

Seventy-five subjects completed the study (41 SUI/34 RUI). The primary endpoint non-inferiority of SUI vs RUI was met, with no significant difference between SUI and RUI in most radiographic parameters (distal femoral varus-valgus, proximal tibial varus-valgus, tibial slope, or subjects within 3° of target); there was a slight difference in femoral component flexion angle (P = .015). SUI and RUI mean (SD) OR set-up times were 18.8 (10.03) and 26.7 (6.93) (P <.001), and surgical times (first incision to last stitch) were 64.6 (16.95) and 60.5 (19.01) (P = .295), respectively. Differences in OR clean-down and anesthesia were not significant. There were no revisions, and there was no significant difference in the number of reported adverse events.

CONCLUSION

SUI resulted in similar accuracy of implant placement to RUI with decreased OR set-up time and no increase in adverse events. These results support the safety and efficacy of SUI for performing TKA. Further analysis of potential economic and technical advantages is warranted.

Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty

BACKGROUND

Over 1 million total joint arthroplasties (TJAs) are performed every year in the United States, creating Medicare cost concerns for policy makers. The purpose of this study is to evaluate recent trends in Medicare utilization and reimbursements to hospitals/surgeons for TJAs between 2012 and 2017.

METHODS

We tracked annual Medicare claims and payments to TJA surgeons using publicly available Medicare databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization (per 10,000 Medicare beneficiaries), and reimbursement rates and to examine associations between county-specific variables and TJA utilization and reimbursements.

RESULTS

Between 2012 and 2017, there was an 18.9% increase in annual primary TJA volume (357,500 cases in 2012 to 425,028 cases in 2017) and a 2.0% increase in annual primary TJA per capita utilization (73.4 cases per 10,000 Medicare beneficiaries in 2012 to 74.8 in 2017). The Midwest and the South had higher utilization rates compared with the Northeast and West (P < .001). Utilization rates for primary TJA procedures also had a significant negative association with the poverty rate (P < .001). Medicare Part B payments to surgeons fell by 7.5%, equivalent to a 14.9% inflation-adjusted decline, whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively, during the study period.

CONCLUSIONS

Despite increasing TJA volume and utilization, surgeon reimbursements have continued to decline, whereas hospital payments and hospital charges have increased significantly more than surgeon charges. Cost containment efforts will need to address other expenditures such as hospital costs and implant costs to better align financial risks and incentives for TJA surgeons.

Trajectories of functional performance and muscle strength recovery differ after total knee and total hip replacement: a performance-based, longitudinal study

Total joint replacement is indicated to alleviate pain and disability associated with hip and knee osteoarthritis. Arthroplasty outcomes are typically reported together, or anecdotal comparisons are made between total knee arthroplasty (TKA) and total hip arthroplasty (THA) recovery. Limited data quantifies differences in recovery trajectories, especially with respect to performance-based outcomes. Seventy-nine people undergoing total knee or THA were followed over 6 months. Functional performance was measured using the stair climb test, timed-up-and-go test, and 6-min walk test. Surgical limb isometric strength was also measured. All outcomes significantly declined 1 month after surgery. Participants in the TKA group showed a greater decline in climbing stairs (P < 0.001), timed-up-and-go (P = 0.01), and 6-min walk distance (P < 0.01). Further, the TKA group lost more strength (P < 0.001) and were weaker than those after THA (P < 0.001). Differences in postoperative outcomes between groups at 3 and 6 months were also observed. The TKA group experiences a greater decline in measured outcomes than the THA group, and muscle strength and functional recovery occurred differently in each group. These findings should be considered in rehabilitation priorities after arthroplasty surgery.

Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses

BACKGROUND

Optimization of surgical instrument trays improves efficiency and reduces cost. The purpose of this study is to assess the economic impact of optimizing orthopedic instrument trays at a tertiary medical center.

METHODS

Twenty-three independent orthopedic surgical instrument trays at a single academic hospital were reviewed from 2017 to 2018. Using Lean methodology, surgeons agreed upon the fewest number of instruments needed for each of the procedure trays. Instrument usage counts, cleaning times, room turnover times, tray weight, holes in tray wrapping, wet trays, and time invested to optimize each tray were tracked. Cost savings were calculated. Student's t-test was used to determine statistical significance, with P < .05 considered significant.

RESULTS

The mean instrument usage before and after Lean optimization was 23.4% and 54.2% (P < .0001). By Lean methods, 433 of 792 instruments (55%) were removed from 11 unique instrument trays (102 total trays), resulting in a reduction of 3520 instruments. Total weight reduction was 574.3 pounds (22%), ranging from 2.1-16.2 pounds per tray. The number of trays with wrapping holes decreased from 13 to 1 (P < .0001). The process of examining and removing instruments took an average of 7 minutes 35 seconds per tray. The calculated total annual savings was $270,976 (20% overall cost reduction).

CONCLUSION

In addition to substantial cost savings, tray optimization decreases tray weights and cleaning times without negatively impacting turnover times. Lean methodology improves efficiency in instrument tray usage, and reduces hospital cost while encouraging surgeon and staff participation through continuous process improvement.

LEVEL OF EVIDENCE

Economic Quality Improvement, Level III.

Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients?

BACKGROUND

Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear.

METHODS

For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay.

RESULTS

Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396).

CONCLUSION

For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

A comparison of peri-operative outcomes between elective and non-elective total hip arthroplasties

Background

Elective total hip arthroplasties (THAs) entail a more extensive pre-operative planning process compared to non-elective THAs and this may contribute to a disparity in outcomes. However, the differences in peri- and post-operative outcomes between elective and non-elective THAs remain unclear. Therefore, the purpose of this study was to: (I) determine nationwide trends in operative times and (II) evaluate the association between surgery type, elective or non-elective with respect to (I) operative times; (II) hospital lengths-of-stay (LOS); (III) discharge disposition; (IV) 30-day post-operative complications; (V) reoperations; and (VI) readmissions.

Methods

The NSQIP database was queried for all primary THAs (CPT code 27130) performed between 2011 and 2016. This yielded 130,261 cases, which were then stratified into elective (n=125,293) and non-elective (n=4,968) cases. One-way analysis of variance (ANOVA) were used to evaluate the associations between operative times and surgery year. Univariate analyses of surgery type with the following outcomes of interest were also performed: operative times, LOS, and discharge disposition as well as 30-day complication, reoperation, and readmission rates. A multiple linear regression model was used to evaluate the relationships of operative times and LOS with surgery types after adjusting for surgery year and patient factors [age, sex, body mass index (BMI), and American Society of Anesthesiologists (ASA) score]. A log-transformed dependent variable was used to calculate the percentage difference in mean operative times and LOS. Multivariate logistic regression models adjusted for patient factors and year of surgery were used to evaluate associations of surgery type with complication, reoperation, and readmission rates.

Results

Over the 6-year period, mean operative times (93 vs. 103 minutes, P<0.001) and LOS (3 vs. 6 days, P<0.001) were significantly shorter in elective cases compared to non-elective cases. The relationships between operative times or LOS and surgery type remained significant even after adjusting for age, sex, BMI, ASA, and year of surgery (P<0.001). Compared to the non-elective cohort, patients in the elective cohort were more likely to be discharged home (74% vs. 69%, P<0.001). Elective patients had lower rates of several 30-day complications including deep SSI (P<0.001), transfusions (P<0.001), sepsis (P<0.001), and readmission (P<0.005) compared to non-elective patients. These associations remained significant after accounting for potential confounders with multivariate logistic regression.

Conclusions

Findings from this study showed that elective THAs, in which there is more potential for pre-operative planning, were associated with shorter operative times and LOS, as well as fewer complication and readmission rates. These results likely reflect the development of more efficient surgical techniques and improved pre- and intra-operative planning guides.

A Surgeon Scorecard Is Associated with Improved Value in Elective Primary Hip and Knee Arthroplasty

BACKGROUND

Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs.

METHODS

We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05.

RESULTS

After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05).

CONCLUSIONS

The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes.

CLINICAL RELEVANCE

Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

Quadratus lumborum block provides improved immediate postoperative analgesia and decreased opioid use compared with a multimodal pain regimen following hip arthroscopy

The purpose of our study was to evaluate the effect on immediate patient outcomes following hip arthroscopy with use of a preoperative, single shot quadratus lumborum (QL) block. We retrospectively reviewed patients who underwent hip arthroscopy following a preoperative QL block. These patients were matched by age and gender to patients who had not received a block. Visual analogue scale (VAS) pain scores immediately postoperatively and at the time of discharge were recorded. Hourly and overall opioid intake in the postanesthesia care unit (PACU) was also recorded. Continuous data was analysed with paired t-test, with significance being defined as P < 0.05. Complications in the immediate postoperative period were recorded, as was time from admission to PACU to discharge. Fifty-six patients were included. Twenty-eight patients underwent QL block and 28 did not undergo a block. QL block patients required significantly less hydromorphone (P = 0.010) and oxycodone (P = 0.001) during their time in the PACU, and significantly fewer morphine equivalents overall and per hour in the PACU (P < 0.001). Despite receiving less opioid analgesia, QL block patients had significantly less pain immediately postoperatively (P = 0.026) and at the time of discharge (P = 0.015). The mean time to PACU discharge was 155 ± 49 min, and there was no difference in time to discharge between groups (P = 0.295). One patient in the QL block group experienced persistent flank numbness. Hip arthroscopy patients who received a preoperative QL block had less pain and a lower opioid requirement in PACU than those who did not receive a block.

Level of Evidence: Level III (Retrospective matched cohort study).

Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System

BACKGROUND

Previous studies evaluating reasons for 30-day readmissions following total joint arthroplasty (TJA) may underestimate hospital-based utilization of healthcare resources during a patient's episode-of-care. We sought to identify common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary elective unilateral TJA.

METHODS

Patients from July 1, 2012 through June 30, 2015 having primary elective TJA and at least one 90-day postoperative ED-only visit and/or readmission for any reason were identified using the Kaiser Permanente Total Joint Replacement Registry. Chart reviews for ED visits/readmissions included 13 surgical and 11 medical reasons. The 2344 total hips and 5520 total knees were analyzed separately.

RESULTS

Incidence of at least one ED visit following total hip arthroplasty (THA) was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%) and pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%). The incidence of at least one ED visit following total knee arthroplasty (TKA) was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%) and swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anesthesia (9.4%).

CONCLUSION

Swelling and pain related to the procedure were the most frequent reasons for 90-day ED visits after both THA and TKA. Readmissions were most commonly due to infection or unrelated procedures for THA and gastrointestinal or manipulation under anesthesia for TKA. Modifications to discharge protocols may help prevent or alleviate these issues, avoiding unnecessary hospital returns.

Who Goes to Inpatient Rehabilitation or Skilled Nursing Facilities Unexpectedly Following Total Knee Arthroplasty?

BACKGROUND

Inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) represent a significant portion of post-operative expenses of bundled payments for total knee arthroplasty (TKA). Although many surgeons no longer routinely send patients to IRFs or SNFs, some patients are unable to be discharged directly home. This study identified patient factors for discharge to post-acute care facilities with an institutional protocol of discharging TKA patients home.

METHODS

A retrospective review of patients undergoing primary unilateral TKA at a single institution from 2012 to 2017 was performed. All surgeons discharged patients home as a routine protocol. An electronic query followed by manual review identified discharge disposition, demographic factors, co-morbidities, and other patient factors. In total, 2281 patients were identified, with 9.6% discharged to SNFs or IRFs and 90.4% discharged home. Univariate and multivariate analyses were conducted to create 2 predictive models for patient discharge: pre-operative visit and hospital course.

RESULTS

Among 43 variables studied, 6 were found to be significant pre-operative risk factors for a discharge disposition other than home. In descending order, age 75 or greater, female, non-Caucasian race, Medicare status, history of depression, and Charlson Comorbidity Index were predictors for patients going to IRFs. In addition, any in-hospital complications led to a higher likelihood of being discharged to IRFs and SNFs. Both models had excellent predictive assessments with area under curve values of 0.79 and 0.80 for pre-operative visit and hospital course.

CONCLUSION

This study identifies pre-operative and in-hospital factors that predispose patients to non-routine discharges, which allow surgeons to better predict patient post-operative disposition.

State Variation in Medicaid Reimbursements for Orthopaedic Surgery

BACKGROUND

Medicaid reimbursements are determined by each state and are subject to variability. We sought to quantify this variation for commonly performed inpatient orthopaedic procedures.

METHODS

The 10 most commonly performed inpatient orthopaedic procedures, as ranked by the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, were identified for study. Medicaid reimbursement amounts for those procedures were benchmarked to state Medicare reimbursement amounts in 3 ways: (1) ratio, (2) dollar difference, and (3) dollar difference divided by the relative value unit (RVU) amount. Variability was quantified by determining the range and coefficient of variation for those reimbursement amounts.

RESULTS

The range of variability of Medicaid reimbursements among states exceeded $1,500 for all 10 procedures. The coefficients of variation ranged from 0.32 (hip hemiarthroplasty) to 0.57 (posterior or posterolateral lumbar interbody arthrodesis) (a higher coefficient indicates greater variability), compared with 0.07 for Medicare reimbursements for all 10 procedures. Adjusted as a dollar difference between Medicaid and Medicare per RVU, the median values ranged from -$8/RVU (total knee arthroplasty) to -$17/RVU (open reduction and internal fixation of the femur).

CONCLUSIONS

Variability of Medicaid reimbursement for inpatient orthopaedic procedures among states is substantial. This variation becomes especially remarkable given recent policy shifts toward focusing reimbursements on value.

Does gender influence how patients rate their patient experience after total hip arthroplasty?

BACKGROUND

Patient satisfaction, as measured by Press Ganey (PG) surveys, partially determines reimbursement rates. Knowing what influences these scores can lead to higher reimbursement for total hip arthroplasty (THA) surgeons. Currently, it is unknown whether gender biases exist in satisfaction surveys post-THA. Therefore, we asked: (i) which PG survey factors most influence hospital ratings among men and women after THA; and (ii) is there a difference in survey element responses and overall hospital ratings between men and women post-THA?

METHODS

We queried the PG database for patients who underwent THA from November 2009 to January 2015, which yielded 692 patients (277 men, 415 women). Weighted means were analysed for the scores of PG domains between men and women. A multiple regression analysis was performed for each gender, with overall hospital satisfaction as the dependent variable, in order to assess the influence (β-weight) of each PG domain.

RESULTS

For men, pain management (β = 0.317, p = 0.021) most influenced overall hospital rating. For women, staff responsiveness (β = 0.451, p<0.001) most influenced overall hospital rating. This was followed by communication with nurses (β = 0.373, p<0.001), and doctors (β = 0.236, p = 0.002). There were no significant differences in mean overall hospital rating between groups.

CONCLUSIONS

It is advantageous for orthopaedic surgeons to focus on the PG domains most pertinent to each patient gender post-THA. Focusing efforts based on gender may allow for better patient satisfaction, optimised reimbursements, and improved hospital ratings.

Economic Considerations of Acute Pain Medicine Programs

Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.

Drivers of Medicare Reimbursement for Thoracolumbar Fusion: An Analysis of Data From The Centers For Medicare and Medicaid Services

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

The purpose of this study is to examine the variation in thoracolumbar fusion (TLF) payment and determine the drivers of this variation.

SUMMARY OF BACKGROUND DATA

As health care spending continues to increase, variation in surgical procedures reimbursements has come under more scrutiny. TLF is an example of a high-cost, proven-benefit procedure that is often the focus of Centers for Medicare and Medicaid Services (CMS) administrators. There is a wide variation in TLF charges, but the drivers for this variation are not clear.

METHODS

Claims for TLF were identified in the CMS data by analyzing Diagnosis Related Group (DRG) number 460 ("Spinal Fusion Except Cervical without Major Complications or Comorbidities"). Data on factors that may impact cost of care were collected from four sources: the United States Census Bureau, CMS, the Dartmouth Atlas, and WWAMI Rural Health Research Center. These were then grouped into seven categories: quality, supply, demand, substitute treatment availability, patient characteristics, competitive factors, and provider characteristics. Predictive reimbursement models were created from the data using multivariate linear regression to understand the factors that influence TLF reimbursement.

RESULTS

There was significant geographic variability in reimbursement. The largest contribution to reimbursement variation came from variables in the demand (ΔR = 13.4%, P < 0.001), supply (ΔR = 9.2%, P < 0.001), and competitive factor domains (ΔR = 9.1%, P < 0.001). The top three drivers that increased reimbursement were provider charges (β = 0.37, P < 0.001), total Medicare reimbursement in the region (β = 0.19, P < 0.001), and the number of spinal surgeries per 1000 patients in that region (β = 0.06, P = 0.02). Institutional volume, a surrogate for quality was negatively associated with TLF reimbursement.

CONCLUSION

There was wide variation in reimbursement for TLF across the U.S. The variables that drive TLF reimbursement variation include supply, demand, and competition. Interestingly, quality of care was not associated with increased TLF reimbursement.

LEVEL OF EVIDENCE

N/A.

Factors Influencing Orthopedic Surgery Residents' Choice of Subspecialty Fellowship

In the setting of increasing student debt, a rapidly changing health care system, and growing transparency in the age of outcome reporting, residents have many factors to consider when determining which fellowship to pursue. An institutional review board-approved link to an online survey was emailed to orthopedic surgery trainees across the United States. Demographics were collected, and 14 fellowship influences were assessed using a Likert scale. A total of 360 responses were received. Of the respondents, 85.5% (n=308) were male and 14.5% (n=52) were female. Responses were received from every region of the United States and from every postgraduate year. Respondents represented the gamut of relationship status and indebtedness. Respondents were interested in all of the current major subspecialties. Pursuit of an intellectually stimulating subspecialty had the highest average Likert score (3.38), followed by variety of cases (3.26). The lowest scores were for residency program with a strong tradition of placing into a particular subspecialty (2.08) and potential to conduct research in that subspecialty (2.09). Marital status, number of children, and level of debt did not significantly affect the importance of factors in selecting a fellowship. Choice of subspecialty did influence the level of importance of various factors. Intellectual stimulation and a strong mentor were the most influential factors in the decision to pursue a given fellowship. Because fellowship is now the norm, it is important to understand the motives behind young orthopedic surgeons' career aspirations. [Orthopedics. 2017; 40(5):e820-e824.].

Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study

BACKGROUND

Although HbA1c is commonly used for assessing glycemic control before surgery, there is no consensus regarding its role and the appropriate threshold in predicting adverse outcomes. This study was designed to evaluate the potential link between HbA1c and subsequent periprosthetic joint infection (PJI), with the intention of determining the optimal threshold for HbA1c.

METHODS

This is a multicenter retrospective study, which identified 1645 diabetic patients who underwent primary total joint arthroplasty (1004 knees and 641 hips) between 2001 and 2015. All patients had an HbA1c measured within 3 months of surgery. The primary outcome of interest was a PJI at 1 year based on the Musculoskeletal Infection Society criteria. Secondary outcomes included orthopedic (wound and mechanical complications) and nonorthopedic complications (sepsis, thromboembolism, genitourinary, and cardiovascular complications). A regression analysis was performed to determine the independent influence of HbA1c for predicting PJI.

RESULTS

Overall 22 cases of PJI occurred at 1 year (1.3%). HbA1c at a threshold of 7.7 was distinct for predicting PJI (area under the curve, 0.65; 95% confidence interval, 0.51-0.78). Using this threshold, PJI rates increased from 0.8% (11 of 1441) to 5.4% (11 of 204). In the stepwise logistic regression analysis, PJI remained the only variable associated with higher HbA1c (odds ratio, 1.5; confidence interval, 1.2-2.0; P = .0001). There was no association between high HbA1c levels and other complications assessed.

CONCLUSION

High HbA1c levels are associated with an increased risk for PJI. A threshold of 7.7% seems to be more indicative of infection than the commonly used 7% and should perhaps be the goal in preoperative patient optimization.

Use of the Medicare database in epidemiologic and health services research: a valuable source of real-world evidence on the older and disabled populations in the US

Medicare is the federal health insurance program for individuals in the US who are aged ≥65 years, select individuals with disabilities aged <65 years, and individuals with end-stage renal disease. The Centers for Medicare and Medicaid Services grants researchers access to Medicare administrative claims databases for epidemiologic and health outcomes research. The data cover beneficiaries’ encounters with the health care system and receipt of therapeutic interventions, including medications, procedures, and services. Medicare data have been used to describe patterns of morbidity and mortality, describe burden of disease, compare effectiveness of pharmacologic therapies, examine cost of care, evaluate the effects of provider practices on the delivery of care and patient outcomes, and explore the health impacts of important Medicare policy changes. Considering that the vast majority of US citizens ≥65 years of age have Medicare insurance, analyses of Medicare data are now essential for understanding the provision of health care among older individuals in the US and are critical for providing real-world evidence to guide decision makers. This review is designed to provide researchers with a summary of Medicare data, including the types of data that are captured, and how they may be used in epidemiologic and health outcomes research. We highlight strengths, limitations, and key considerations when designing a study using Medicare data. Additionally, we illustrate the potential impact that Centers for Medicare and Medicaid Services policy changes may have on data collection, coding, and ultimately on findings derived from the data.