What Financial Incentives Will Be Created by Medicare Bundled Payments for Total Hip Arthroplasty?

Risk Factors for Increased Hospital Costs for Primary Total Hip Arthroplasty

BACKGROUND

Patient medical complexity increases the cost of primary total hip arthroplasty (THA). The goal of this study was to quantify the impact of specific medical comorbidities on the real hospital cost of primary THA.

METHODS

This study consisted of a retrospective analysis of 1,222 patient encounters for Current Procedural Terminology code 27130 (primary THA) between January 2017 and March 2020 at a high-volume urban academic medical center. Patient demographics, comorbidities, and admission data were collected, and univariate and multivariate gamma regression analyses were performed to identify associations with increased costs incurred during THA admission.

RESULTS

The median total cost for THA was $30,580. Univariate analysis showed increased cost for body mass index (BMI) > 35 versus BMI < 35 ($31,739 versus 30,071; P < .05), American Society of Anesthesiologists (ASA) score 3 to 4 versus ASA 1 to 2 ($32,268 versus 30,045; P < .05), prevalence of diabetes ($31,523 versus 30,379; P < .05), congestive heart failure ($34,814 versus 30,584; P < .05), peripheral vascular disease (PVD) ($35,369 versus 30,573; P < .05), chronic pulmonary disease (CPD) ($34,625 versus 30,405; P < .05), renal disease ($31,973 versus 30,352; P < .05), and increased length of stay (r = 0.424; P < .05). Multivariate gamma regression showed that BMI > 35 (relative risk [RR] = 1.05), ASA 3 to 4 (RR = 1.07), PVD (RR = 1.29), CPD (RR = 1.13), and renal disease (RR = 1.09) were independently associated with increased THA hospital cost (P < .01). Increased costs seen in BMI > 35 versus BMI < 35 patients were largely due to hospital room and board ($6,345 versus 5,766; P = .01) and operating room costs ($5,744 versus 5,185; P < .05).

CONCLUSIONS

A BMI > 35, PVD, CPD, renal disease, and ASA 3 to 4 are associated with higher inpatient hospital costs for THA.

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair

BACKGROUND

This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed.

METHODS

A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios.

RESULTS

Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%.

CONCLUSIONS

This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

The Off-Table Technique Increases Operating Room Efficiency in Direct Anterior Hip Replacement

Background

When performing a total hip arthroplasty via the direct anterior approach (DAA), many orthopedic surgeons utilize an orthopedic traction table. This technique requires an expensive table, time for positioning, staff to operate the table, and time-consuming transitions when preparing the femur. Some surgeons advocate for an “off-table” technique to avoid these difficulties. In this paper, we compare operating room efficiency between on-table and off-table techniques.

Material and methods

We retrospectively reviewed patients undergoing total hip arthroplasty by a single surgeon across the transition from on-table to off-table DAA technique. Three cohorts were defined; the last 40 on-table hips, the first 40 off-table hips, followed by the second 40 hips. Timestamps from the operative record were recorded to calculate setup, surgical, takedown, and total room time. Implant fixation, patient demographic data, comorbidities, and complications were recorded.

Results

From cohort 1 to 2, there was a 7-minute (14.44%, P = .0002) improvement in setup time but no change in total room time. From cohort 2 to 3, there was an additional 7-minute (15.47%, P < .0001) improvement in setup time, 32-minute (25.88%, P < .0001) improvement in surgical time, and 40-minute (21.96%, P < .0001) improvement in total room time yielding cumulative changes from cohort 1 to 3 of 15 minutes (27.68%, P < .0001), 28 minutes (23.11%, P < .0001), and 43 minutes (23.37%, P < .0001), respectively. There was no correlation between height, weight, or body mass index and time at any interval.

Conclusion

Conversion to an off-table DAA technique offers an improvement in operating room efficiency. This is seen in setup, operative, and total room time. Implementation could allow for an additional case each day.

Staging Total Hip and Knee Arthroplasty Procedures Within 90 Days Increases Costs in Bundled Payment Programs

BACKGROUND

Under current Medicare bundled payment programs, when a patient undergoes a subsequent elective procedure within the 90-day episode-of-care, the first procedure is excluded from the bundle and a new episode-of-care initiated. The purpose of this study was to determine if staging bilateral total hip (THA) and total knee arthroplasty (TKA) procedures within 90 days have an effect on bundled episode-of-care costs.

METHODS

We reviewed a consecutive series of Medicare patients undergoing staged primary THA and TKA from 2015-2019. Patients who underwent a prior procedure within 90 days were compared to those who had undergone a procedure 90-120 days prior. We then performed a multivariate analysis to identify the independent effect of staging timeframe on costs and outcomes.

RESULTS

Of the 136 patients undergoing a staged bilateral THA or TKA, 48 patients underwent staged procedures within 90 days (35%) and 88 patients between 91-120 days (65%). There were no significant differences observed for demographics, comorbidities, complications, readmissions, or discharge disposition (all P > .05). Patients undergoing a staged procedure within 90 days had increased episode-of-care costs by $2021 (95% CI $11-$4032, P = .049), increased postacute care costs by $2019 (95% CI $66-$3971, P < .001), and reduced per-patient margin by $2868 (95% CI-$866-$4869, P = .005).

DISCUSSION

Patients undergoing staged bilateral THA or TKA within 90 days have increased episode-of-care costs compared to those undergoing a staged procedure from 91-120 days. Since patients may still not be fully recovered from the first procedure, CMS should address the inappropriate allocation of costs to ensure institutions are not penalized.

Body Mass Index, American Society of Anesthesiologists Score, and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty

BACKGROUND

Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable.

METHODS

A retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS.

RESULTS

In total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption.

CONCLUSION

Although ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.

Risk Adjustment for Episode-of-Care Costs After Total Joint Arthroplasty: What is the Additional Cost of Individual Comorbidities and Demographics?

INTRODUCTION

Concerns exist regarding the lack of risk adjustment in alternative payment models for patients who may use more resources in an episode of care. The purpose of this study was to quantify the additional costs associated with individual medical comorbidities and demographic variables.

METHODS

We reviewed a consecutive series of primary total hip and knee arthroplasty patients at our institution from 2015 to 2016 using claims data from Medicare and a single private insurer. We collected demographic data and medical comorbidities for all patients. To control for confounding variables, we performed a stepwise multivariate regression to determine the independent effect of medical comorbidities and demographics on 90-day episode-of-care costs.

RESULTS

Six thousand five hundred thirty-seven consecutive patients were identified (4,835 Medicare and 1,702 private payer patients). The mean 90-day episode-of-care cost for Medicare and private payers was $19,555 and $30,020, respectively. Among Medicare patients, comorbidities that significantly increased episode-of-care costs included heart failure ($3,937, P < 0.001), stroke ($2,604, P = 0.002), renal disease ($2,479, P = 0.004), and diabetes ($1,368, P = 0.002). Demographics that significantly increased costs included age ($221 per year, P < 0.001), body mass index (BMI; $106 per point, P < 0.001), and unmarried marital status ($1896, P < 0.001). Among private payer patients, cardiac disease ($4,765, P = 0.001), BMI ($149 per point, P = 0.004) and age ($119 per year, P = 0.002) were associated with increased costs.

DISCUSSION

Providers participating in alternative payment models should be aware of factors (cardiac history, age, and elevated BMI) associated with increased costs. Further study is needed to determine whether risk adjustment in alternative payment models can prevent problems with access to care for these high-risk patients.

Free Falling: Declining Inflation-Adjusted Payment for Arthroplasty Surgeons

BACKGROUND

Over the past decade, there have been ongoing concerns over declining surgeon compensation for lower extremity arthroplasty. We aimed to determine changes in surgeon payment, patient charges, and overall reimbursement rates for patients undergoing unicompartmental arthroplasty (UKA) and both primary and revision total knee (TKA) and hip (THA) arthroplasty.

METHODS

Using Medicare data from 2012 to 2017, we determined inflation-adjusted changes in annual surgeon payment (professional fee), patient charges, and reimbursement rate (payment-to-charge ratio) for UKA and primary/revision TKA and THA. Both nonweighted and weighted (by procedure frequency/volume) means were calculated.

RESULTS

Inflation-adjusted surgeon payment decreased for all procedures analyzed, with primary TKA (-17%) and THA (-11%) falling the most. Payment for UKA increased the most (+30%). There was a small increase in charges for THA revision (+2.2%, +2.1%, and +3.2% for acetabulum only, femur only, and both components, respectively). Charges for primary TKA (-3.7%) and THA (-1.5%) decreased slightly. The reimbursement rate for all procedures fell with UKA (-15%), TKA (-14%), and THA (-10%) falling the most. After weighting by procedure frequency/volume and combining all surgeries, average charges fell slightly (-0.7%), whereas surgeon payment (-13%) and reimbursement rate (-12%) fell more sharply.

CONCLUSION

Although patient charges have grown in pace with the inflationary rate for primary and revision TKA and THA, surgeon payment and reimbursement rates have fallen sharply. The orthopedic community needs to be aware of these financial trends to communicate to payers and health care policy makers the importance of protecting a sustainable payment infrastructure.

Metric Selection, Metric Targets, and Risk Adjustment Should be Considered in the Design of Gainsharing Models for Bundled Payment Programs in Total Joint Arthroplasty

BACKGROUND

Under bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons' performance in gainsharing models.

METHODS

Patients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons' performance designation: scenario 1 used "aspirational targets" (>60th percentile), scenario 2 used "acceptable targets" (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool.

RESULTS

In total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance.

CONCLUSION

Quality metric/target selection and risk adjustment profoundly impact surgeons' performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the "cherry picking" of patients.

LEVEL OF EVIDENCE

Level III.

Health Care Utilization and Costs in the Year Prior to Arthroscopic Rotator Cuff Repair

Background:

A majority of cost-control strategies in arthroscopic rotator cuff repair (RCR) have been concentrated on the perioperative and post–acute care periods, with the preoperative health care period being largely overlooked.

Purpose:

To report the distribution of costs associated with health care utilization within the year prior to arthroscopic RCR.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2007 through 2015 (third quarter) Humana Administrative Claims database was queried using Current Procedural Terminology code 29827 to identify patients undergoing arthroscopic RCR for only degenerative rotator cuff tears. The study cohort was divided into 2 distinct groups based on insurance plan: commercial or Medicare Advantage (MA). Total 1-year costs, per-patient average reimbursements (PPARs), and trends in utilization for the following preoperative health care resource categories were studied: office visits, radiographs, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, steroid injections, hyaluronic acid (HA) injections, physical therapy, and pain medications (opioids + nonopioids).

Results:

A total of 18,457 MA and 6530 commercial beneficiaries undergoing arthroscopic RCR over the study period were included. Total 1-year preoperative costs (in US$) amounted to $16,923,595 ($916/patient) and $8,397,291 ($1285/patient) for MA and commercial beneficiaries, respectively. The largest proportion of total 1-year costs for both MA and commercial beneficiaries was accounted for by MRI scans (36% and 56%, respectively). PPARs for each health care resource category were as follows: office visits (MA, $240; commercial, $249), radiographs (MA, $60; commercial, $93), MRI scans (MA, $385; commercial, $813), CT scans (MA, $223; commercial, $562), steroid injections (MA, $97; commercial, $137), HA injections (MA, $422; commercial, $602), physical therapy (MA, $473; commercial, $551), and pain medications (MA, $208; commercial, $136). High health care utilization within the past 3 months before surgery was noted for radiographs, physical therapy, opioids, steroid injections, and office visits, with up to 40% to 90% of 1-year PPARs being accounted for within this time period alone.

Conclusion:

Approximately $900 to $1300 per patient was spent in rotator cuff–related health care resource use in the year prior to undergoing arthroscopic RCR. As we begin to implement value in shoulder surgery, judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs.

Determinants of Cost Variation in Total Hip and Knee Arthroplasty: Implications for Alternative Payment Models

BACKGROUND

Alternative payment models have been proposed to deliver high-quality, cost-effective care. Under these models, payments may be shared between the hospital and the post-acute care services. Post-acute care services may account for one-third of the episode costs for total hip or knee arthroplasty (THA/TKA). Because hospitals or episode initiators bear notable financial risks in these payment models with minimal risk adjustment for complexity, it has been suggested these models may lead to prospective selection of healthier and younger patients. Studies evaluating the effect of patient demographics, medical complexity, and surgical characteristics on the cost of index hospitalization have been limited. We aimed to (1) quantify the impact of patient demographics, medical complexity, and surgical characteristics (type of anesthesia and operating time) on variation in direct cost of index hospitalization and (2) examine the association of these characteristics with discharge with home health services or to rehabilitation facility.

METHODS

Retrospective study of 3,542 patients admitted to our hospital for elective THA/TKA between 2012 and 2017. Multivariable generalized estimating equations were used for analysis.

RESULTS

Patient demographics and medical complexity accounted for 6.2% (THA) and 5.6% (TKA) of variation in direct cost of index hospitalization. Surgical characteristics accounted for 37.1% (THA) and 35.3% (TKA) of the cost variation. One thousand one hundred eighty-three (53.4%) patients were discharged with home health services, and 1,237 (29.4%) were discharged to rehabilitation facility. Patient demographics and higher medical complexity were markedly associated with discharge with home health services or to rehabilitation facility after THA/TKA.

DISCUSSION

Patient demographics and medical complexity had minimal impact on variation in direct cost of index hospitalization for elective THA/TKA compared with surgical characteristics but were markedly associated with discharge with home health services or to rehabilitation facility. Having additional risk adjustment in these payment models could mitigate concerns about access to care for higher risk, higher cost patients.

Differential Use of Narcotics in Total Hip Arthroplasty: A Comparative Matched Analysis Between Osteoarthritis and Femoral Neck Fracture

BACKGROUND

The United States is currently in an opioid epidemic as it consumes the majority of narcotic medications. The purpose of this investigation is to identify the incidence and risk factors for prolonged opioid usage following total hip arthroplasty (THA) due to hip fracture (Fx) or osteoarthritis (OA).

METHODS

The PearlDiver database was reviewed for patients undergoing THA from 2007 through the first quarter of 2017. Following a 3:1 match based on comorbidities and demographics, patients were divided into THA due to Fx (n = 1801) or OA (n = 5403). Preoperative and prolonged postoperative narcotic users were identified. Multivariate logistic regression analysis was performed to identify demographics, comorbidities, or diagnoses as risk factors for prolonged opioid use and preoperative and postoperative opioid use as risk factors for complications.

RESULTS

One thousand seven hundred ninety-four OA patients (33.2%) were prescribed narcotics preoperatively and 1655 patients (30.6%) were using narcotics postoperatively, while 418 Fx patients (23.2%) were prescribed narcotics preoperatively and 499 patients (27.7%) were using narcotics postoperatively. Diagnosis of Fx (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.28-1.72, P < .001) and preoperative narcotic use (OR 6.12, 95% CI 5.27-6.82, P < .001) were the most significant risk factors for prolonged postoperative narcotic use. Prolonged postoperative narcotic use was associated with increased infection, dislocation, and revision THA in both Fx and OA groups.

CONCLUSION

Diagnosis of femoral neck fracture and overall preoperative narcotic use were significant predictors of chronic postoperative opioid use. Patients with significant risk factors for opioid dependence should receive additional consultation and more prudent follow-up with regards to pain management.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Dialysis Dependence Is Associated With Significantly Increased Odds of Perioperative Adverse Events After Geriatric Hip Fracture Surgery Even After Controlling for Demographic Factors and Comorbidities

Previous studies evaluating the risk of perioperative adverse events after hip fracture surgery for dialysis-dependent patients are either institutional cohort studies or limited by patient numbers. The current study uses the National Surgical Quality Improvement Program database's large national patient population and 30-day follow-up window to address these weaknesses.

Not all hip arthroplasties are created equal

Aims

Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNFs), especially in physiologically younger patients. While THA for osteoarthritis (OA) has demonstrated low complication rates and increased quality of life, results of THA for acute FNF are not as clear. Currently, a THA performed for FNF is included in an institutional arthroplasty bundle without adequate risk adjustment, potentially placing centres participating in fracture care at financial disadvantage. The purpose of this study is to report on perioperative complication rates after THA for FNF compared with elective THA performed for OA of the hip.

Patients and Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2008 and 2016 was queried. Patients were identified using the THA Current Procedural Terminology (CPT) code and divided into groups by diagnosis: OA in one and FNF in another. Univariate statistics were performed. Continuous variables were compared between groups using Student’s t-test, and the chi-squared test was used to compare categorical variables. Multivariate and propensity-matched logistic regression analyses were performed to control for risk factors of interest.

Results

Analyses included 139 635 patients undergoing THA. OA was the indication in 135 013 cases and FNF in 4622 cases. After propensity matching, mortality within 30 days (1.8% vs 0.3%; p < 0.001) and major morbidity (24.2% vs 19%; p < 0.001) were significantly higher among FNF patients. Re-operation (3.7% vs 2.7%; p = 0.014) and re-admission (7.3% vs 5.5%; p = 0.002) were significantly higher among FNF patients. Hip fracture patients had significantly longer operative time and length of stay (LOS), and were significantly less likely to be discharged to their home. Multivariate analyses gave similar results.

Conclusion

This large database study showed a higher risk of postoperative complications including mortality, major morbidity, re-operation, re-admission, prolonged operative time, increased LOS, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. While THA is a good option for FNF patients, there are increased costs and financial risks to centres with a joint arthroplasty bundle programme participating in fracture care. Cite this article: Bone Joint J 2019;101-B(6 Supple B):84–90.

Are Medicare's "Comprehensive Care for Joint Replacement" Bundled Payments Stratifying Risk Adequately?

BACKGROUND

Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program.

METHODS

Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period.

RESULTS

Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R² = 0.23 vs 0.17).

CONCLUSION

More robust risk stratification could provide more equitable reimbursement in the CJR program.

LEVEL OF EVIDENCE

Large database analysis; Level III.

Dialysis Dependence Predicts Complications, Intensive Care Unit Care, Length of Stay, and Skilled Nursing Needs in Elective Primary Total Knee and Hip Arthroplasty

BACKGROUND

Limited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients.

METHODS

Retrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non-dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences.

RESULTS

Six hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P < .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P < .001), discharge to facility (RR = 1.3, P < .001), and longer admission (1.5×, P < .001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P < .001), ICU care (RR = 6.0, P < .001), stroke (RR = 7.6, P < .001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P < .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P < .001).

CONCLUSION

Dialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models.

Differences in Post-Operative Outcome Between Conversion and Primary Total Hip Arthroplasty

BACKGROUND

The demand for conversion of prior hip surgery to total hip arthroplasty (conversion THA) is likely to increase as a function of increasing US hip fracture burden in addition to its application in managing other conditions. Thus, outcome analysis is warranted to better inform value-based reimbursement schemes in the era of bundled payments.

METHODS

Via Current Procedural Terminology codes, the National Surgical Quality Improvement Project data files were queried for all patients who underwent primary THA and conversion of previous hip surgery to THA from 2005 to 2014. To better understand the isolated effect of procedure type on adverse outcomes, primary and conversion cohorts were then propensity-score matched via logistic regression modeling. Comparisons of the study's primary outcomes were drawn between matched cohorts. Statistical significance was defined by a P-value less than or equal to .05.

RESULTS

Relative to the primary THA group, the conversion THA group had statistically greater rates of Center Medicare and Medicaid Services (CMS) complications (7.5% vs 4.5%), non-home bound discharge (19.6% vs 14.7%), and longer length of hospital stay. Conversion THA was associated with increased likelihood of CMS complications (odds ratio 1.68, confidence interval 1.39-2.02) and non-home bound discharge (odds ratio 1.41, confidence interval 1.25-1.58). No statistically significant differences in mortality and readmission were detected.

CONCLUSION

The elevated risk for CMS-reported complications, increased length of hospital stay, and non-home bound discharge seen in our study of conversion THA indicates that it is dissimilar to elective primary THA and likely warrants consideration for modified treatment within the Comprehensive Care for Joint Replacement structure in a manner similar to THA for fracture.

Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.].

Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program

BACKGROUND

The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments.

METHODS

We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement.

RESULTS

The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p < 0.01). Younger age was also associated with higher payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p < 0.01). Most comorbidities were associated with higher reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p < 0.01). Twenty-two procedure codes are included in the bundle, and patients with the 3 most common codes accounted for 98% of the cases, with average reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p < 0.01). DRGs also showed significant differences in reimbursement (p < 0.01); e.g., DRG 480 was reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15).

CONCLUSIONS

Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that patients retain access to care. At a minimum, payments should be adjusted for age, comorbidities, demographic factors, geographic location, and surgical procedure.

Is Rapid Recovery Hip and Knee Replacement Possible and Safe in the Octogenarian Patient?

BACKGROUND

Rapid recovery programs are now aimed to reduce costs of hip and knee arthroplasties by discharging patients directly home, shortening hospital length of stay (LOS), and reducing readmission rates. Although patients aged 80 years and older are included in the Medicare bundle, little work has been performed to determine if older patients can safely participate in rapid recovery programs.

METHODS

We retrospectively reviewed 2482 patients undergoing primary and revision total hip and knee arthroplasties (THA and TKA) who all participated in a multifaceted rapid recovery program. The goals of this program were next day discharge to home without the use of home services or post-acute care admission. We examined the hospital LOS and the percentage of patients discharged home as well as 90-day readmission rates to determine efficacy and safety of this program in the patients aged 80 years and older.

RESULTS

Octogenarians receiving primary THA and TKA were discharged home >90% of the time with LOSs <2 days and low readmission rates. Revision THA and TKA patients aged 80 years and older were discharged home about 70% of the time with significantly longer LOSs than patients aged more than 80 years. The revision THA patients aged more than 80 years had the highest readmission rates.

CONCLUSION

Patients aged more than 80 years can successfully and safely participate in rapid recovery programs.

Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty

BACKGROUND

In the current health care environment, it is becoming increasingly important to recognize risks factors that may affect a patient's postoperative outcome. To determine the potential impact of tobacco as a risk factor, we evaluated postoperative pain, narcotic use, length of stay, reoperations, and complications in the global 90-day episode of care for patients undergoing anatomic total shoulder arthroplasty (TSA) who were current tobacco users, former users, or nonusers.

METHODS

Database search identified 163 patients with primary anatomic TSA done for glenohumeral arthritis; these were divided into 3 groups: current tobacco users (28), nonusers (88), and former users (47). All surgeries were done with the same technique and implants.

RESULTS

Patients in the current tobacco use group had significantly higher visual analog scale scores preoperatively and at 12 weeks postoperatively than nonusers and former users. Mean improvement in visual analog scale scores was significantly less in current tobacco users. Cumulative oral morphine equivalent use at 12 weeks was significantly higher in current tobacco users than in nonusers and former users. The average oral morphine equivalent per day was also significantly higher in the current tobacco users than in nonusers and former users. There were no significant differences in length of stay or complications.

CONCLUSIONS

Although length of stay, complication rates, hospital readmissions, and reoperation rates were not significantly different, tobacco users reported increased postoperative pain and narcotic use in the global period after TSA. Former tobacco users were found to have a postoperative course similar to that of nonusers, suggesting that discontinuation of tobacco use can improve a patient's episode of care performance after TSA.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Differences in Postoperative Outcomes Between Total Hip Arthroplasty for Fracture vs Osteoarthritis

BACKGROUND

Hip fracture is an increasingly common expanded indication for total hip arthroplasty (THA) and warrants outcome analysis so as to best inform risk assessment models, public reporting of outcome, and value-based reimbursement schemes.

METHODS

The National Surgical Quality Improvement Program data file from 2011 to 2014 was used to identify all patients undergoing THA via current procedural terminology code 27130. Propensity score matching in a 1:5 fashion was used to compare 2 cohorts: THA for osteoarthritis and THA for fracture. Primary outcomes included Centers for Medicare and Medicaid Services (CMS) reportable complications, unplanned readmission, postsurgical length of stay, and discharge destination. χ² tests for categorical variables and Student t test for continuous variables were used to compare the 2 cohorts and adjusted linear regression analysis used to determine the association between hip fracture and THA outcomes of interest.

RESULTS

A total of 58,302 patients underwent elective THA for osteoarthritis and 1580 patients underwent THA for hip fracture. Rates of CMS-reported complications (4.0% vs 10.7%; P < .001), non-homebound discharge (39.8% vs 64.7%; P < .001), readmission (4.7% vs 8.0%; P < .001), and mean days of postsurgical hospital stay (3.2 vs 4.4; P < .001) were greater in the hip fracture cohort. THA for hip fracture was significantly associated with increased risk of CMS-reportable complications (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.17-3.28), non-homebound discharge (OR, 1.73; 95% CI, 1.39-2.15), and readmission (OR, 2.78; 95% CI, 2.46-3.12).

CONCLUSION

Our findings support recent advocacy for the exclusion of THA for fracture from THA bundled pricing methodology and public reporting of outcomes.

Fall Risk Score at the Time of Discharge Predicts Readmission Following Total Joint Arthroplasty

BACKGROUND

Readmission among Medicare recipients is a leading driver of healthcare expenditure. To date, most predictive tools are too coarse for direct clinical application. Our objective in this study is to determine if a pre-existing tool to identify patients at increased risk for inpatient falls, the Hendrich Fall Risk Score, could be used to accurately identify Medicare patients at increased risk for readmission following arthroplasty, regardless of whether the readmission was due to a fall.

METHODS

This study is a retrospective cohort study. We identified 2437 Medicare patients who underwent a primary elective total joint arthroplasty (TJA) of the hip or knee for osteoarthritis between 2011 and 2014. The Hendrich Fall Risk score was recorded for each patient preoperatively and postoperatively. Our main outcome measure was hospital readmission within 30 days of discharge.

RESULTS

Of 2437 eligible TJA recipients, there were 226 (9.3%) patients who had a score ≥6. These patients were more likely to have an unplanned readmission (unadjusted odds ratio 2.84, 95% confidence interval 1.70-4.76, P < .0001), were more likely to have a length of stay >3 days (49.6% vs 36.6%, P = .0001), and were less likely to be sent home after discharge (20.8% vs 35.8%, P < .0001). The effect of a score ≥6 on readmission remained significant (adjusted odds ratio 2.44, 95% confidence interval 1.44-4.13, P = .0009) after controlling for age, paralysis, and the presence of a major psychiatric disorder.

CONCLUSION

Increased Hendrich fall risk score after TJA is strongly associated with unplanned readmission. Application of this tool will allow hospitals to identify these patients and plan their discharge.

Medicare reimbursement and orthopedic surgery: past, present, and future

PURPOSE OF REVIEW

This paper reviews the history and structure of Medicare reimbursement with a focus on aspects relevant to the field of orthopedic surgery. Namely, this includes Parts A and B, with particular attention paid to the origins of Diagnosis Related Groups (DRG) and the physician fee schedule, respectively. We then review newer policies affecting orthopedic surgeons.

RECENT FINDINGS

Recent Medicare reforms relevant to our field include readmission penalties, the evolution of bundled payments including the mandatory Comprehensive Care for Joint Replacement (CJR) and Surgical Hip and Femur Fracture Treatment (SHFFT) programs, and the new mandatory Merit-based Incentive Payment System (MIPS) pay-for-performance program. Providers are facing an increasingly complex payment system and are required to assume growing levels of financial risk. Physicians and practices who prepare for these changes will likely fare best and may even benefit.