Free Falling: Declining Inflation-Adjusted Payment for Arthroplasty Surgeons

Geographical Differences in Surgeon Reimbursement, Volume, and Patient Characteristics in Primary Total Hip Arthroplasty

BACKGROUND

The purpose of this study was to evaluate changes in regional and national variations in reimbursement to arthroplasty surgeons, procedural volumes, and patient populations for total hip arthroplasty (THA) from 2013 to 2021.

METHODS

The Medicare Physician and Other Practitioners database was queried for all billing episodes of primary THA for each year between 2013 and 2021. Inflation-adjusted surgeon reimbursement, procedural volume, physician address, and patient characteristics were extracted for each year. Data were stratified geographically based on the United States Census regions and rural-urban commuting codes. Kruskal-Wallis and multivariable regressions were utilized.

RESULTS

Between 2013 and 2021, the overall THA volume and THAs per surgeon increased at the highest rate in the West (+48.2%, +20.2%). A decline in surgeon reimbursement was seen in all regions, most notably in the Midwest (-20.3%). Between 2013 and 2021, the average number of Medicare beneficiaries per surgeon declined by 12.6%, while the average number of services performed per beneficiary increased by 18.2%. In 2021, average surgeon reimbursement was the highest in the Northeast ($1,081.15) and the lowest in the Midwest ($988.03) (P < .001). Metropolitan and rural areas had greater reimbursement than micropolitan and small towns (P < .001). Patient age, race, sex, Medicaid eligibility, and comorbidity profiles differ between regions. Increased patient comorbidities, when controlling for patient characteristics, were associated with lower reimbursement in the Northeast and West (P < .01).

CONCLUSIONS

Total hip arthroplasty (THA) volume and reimbursement differ between US regions, with the Midwest exhibiting the lowest increase in volume and greatest decline in reimbursement throughout the study period. Alternatively, the West had the greatest increase in THAs per surgeon. Patient comorbidity profiles differ between regions, and increased patient comorbidity is associated with decreased reimbursement in the Northeast and the West. This information is important for surgeons and policymakers as payment models regarding reimbursement for arthroplasty continue to evolve.

The 22-Modifier in Total Hip and Knee Arthroplasty: A Comprehensive Analysis

BACKGROUND

The 22-modifier requests additional compensation for increased case complexity. Unfortunately, there is little to guide physicians on the application, which may increase successful reimbursement. We sought to evaluate various factors affecting reimbursement of the 22-modifier in primary total joint arthroplasty (TJA) and report which factors contributed to successful utilization.

METHODS

In this retrospective study, all cases from a single practice where the 22-modifier was added to Current Procedural Terminology codes: 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty) from October 2018 to March 2022 were evaluated. Out of the 6,869 total cases performed, 816 22-modifier cases were identified (11.9%). Operative reports, demographics, insurance type, billing information, and clinical records were assessed. T-tests were used to determine statistical significance.

RESULTS

Of the 816 cases, 221 (27.1%) were successfully reimbursed. Cases justified 22-modifier application with obesity, anatomic variations, or intraoperative factors. Some cases lacked justification, or operative reports were not submitted. Reimbursement was successful for 27.6% of obesity cases, 29.7% of intraoperative complications, and 35.7% of anatomic variations. There was a significantly higher likelihood of Medicare reimbursement than third-party payers or Medicaid (69.6 versus 20.5 and 6.9%) (P < .0001). Additionally, Medicare was more likely to reimburse for obesity (76.6 versus 20.0, and 5.2%), anatomic variations (77.3 versus 22.0%), and intraoperative factors (66.6 versus 21.1, and 1.7%).

CONCLUSIONS

Reimbursement for 22-modifier cases in TJA is unlikely. Obesity was cited for most 22-modifier justifications, but anatomic variation justification was successfully reimbursed most often. Medicare was most likely to reimburse compared to third-party payers or Medicaid. These findings should be considered when applying a 22-modifier to TJA procedures.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BACKGROUND

Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement.

METHODS

A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units.

RESULTS

Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts.

CONCLUSIONS

Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty

BACKGROUND

With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care.

METHODS

A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service.

RESULTS

From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans.

CONCLUSION

From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Delta hemoglobin cutoffs do not predict readmission in patients undergoing primary simultaneous bilateral total hip or knee arthroplasty: A retrospective cohort study

Background/aims

Primary simultaneous bilateral total joint arthroplasty (simBTJA) can cause postoperative anemia. Clinicians might hesitate to discharge patients who have large changes in hemoglobin [Hgb], despite Hgb levels remaining above transfusion thresholds. This study was conducted to evaluate if delta Hgb or perioperative blood loss correspond with readmission in primary simBTJA patients not transfused perioperatively.

Methods

From 2015 - 2020, a retrospective chart review of primary simultaneous bilateral total hip/knee arthroplasty cases was conducted. Preoperative and postoperative Hgb levels were obtained from our database or chart review. Exclusion criteria comprised patients who had a preoperative transfusion or transfusion postoperatively during their surgical admission, and patients not discharged home. Outcomes included whether delta Hgb or perioperative blood loss were predictive of 90-day readmission postoperatively, postoperative anemia, and transfusion during readmission.

Results

The 510 individuals undergoing primary simBTJA possessed an average preoperative Hgb of 14.1 g/dL, starting blood volume of 5012 mL, postoperative Hgb of 10.0 g/dL, delta Hgb of 3.90 g/dL, and perioperative blood loss of 1403 mL. 19 patients (3.73 %) were readmitted, with none requiring transfusion. When constructing receiver operating characteristic (ROC) curves predicting readmission from delta Hgb, a threshold of 4.1 g/dL had an area under the curve (AUC) of 0.454, a sensitivity of 0.473, and a specificity of 0.56. For ROC curves predicting readmission from perioperative blood loss, a threshold of 1144 mL had an AUC of 0.453, a sensitivity of 0.842, and a specificity of 0.297. Similar AUCs, sensitivities, and specificities were obtained when adjusting ROC curves for preoperative Hgb or starting blood volume.

Conclusions

Delta Hgb and perioperative blood loss do not predict 90-day readmission after primary simBTJA in patients not transfused perioperatively. Patients with a large delta Hgb but stay higher than a 7 g/dL restrictive transfusion threshold may have a strong capacity to overcome postoperative anemia.

Medicaid Patients Travel Disproportionately Farther for Revision Total Joint Arthroplasty

BACKGROUND

Access to high-quality care for revision total joint arthroplasty (rTJA) is poorly understood but may vary based on insurance type. This study investigated distance traveled for hip and knee rTJA based on insurance type.

METHODS

A total of 317 revision hips and 431 revision knees performed between 2010 and 2020 were retrospectively reviewed. Cluster sampling was used to select primary hips and knees for comparison. Median driving distance was compared based upon procedure and insurance type.

RESULTS

Revision hip and knee patients traveled 18.2 and 11.0 miles farther for surgery compared to primary hip and knee patients (P ≤ .001). For hip rTJA, Medicaid patients traveled farther than Medicare patients followed by commercially insured patients with median distances traveled of 98.4, 67.2, and 35.6 miles, respectively (P = .016). Primary hip patients traveled the same distance regardless of insurance type (P = .397). For knee rTJA, Medicaid patients traveled twice as far as Medicare and commercially insured patients (medians of 85.0, 43.5, and 42.2 miles respectively, P ≤ .046). Primary knee patients showed a similar pattern (P = .264). Age and ASA-PS classification did not indicate greater comorbidity in Medicaid patients.

CONCLUSION

Insurance type may influence rTJA referrals, with disproportionate referral of Medicaid and Medicare patients to nonlocal care centers. In addition to patient burden, these patterns potentially present a financial burden to facilities accepting referrals. Strategies to improve equitable access to rTJA, while maintaining the highest and most economical standards of care for patients, providers, and hospitals, are encouraged.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis

BACKGROUND

While trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood.

METHODS

The Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions.

RESULTS

The number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (β = 109.07, P ≤ .001) and revision (β = -13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111).

CONCLUSION

The present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

Are Trends in Revision Total Joint Arthroplasty Sustainable? Declining Inflation-Adjusted Medicare Reimbursement for Hospitalizations

BACKGROUND

While the burden of revision total joint arthroplasty (TJA) procedures increases within the United States, it is unclear whether health care resource allocation for these complex cases has kept pace. This study examined the trends in hospital-level reimbursements for revision TJA hospitalizations.

METHODS

The Centers for Medicare and Medicaid Services (CMS) inpatient utilization and payment public use files from 2014 to 2019 were queried for diagnostic-related groups (DRGs) for revision TJA: DRG 467 (revision of hip or knee arthroplasty with complication or comorbidity [CC]) and DRG 468 (revision of hip or knee arthroplasty without CC or major CC). From 2014 to 2019, 170,808 revision TJA hospitalizations were billed to Medicare, and revision TJA procedures increased by 3,121 (10.7%). After adjusting to 2019 US dollars with the consumer price index, a multiple linear mixed-model regression analysis was performed. Analysis of covariance compared regressions from 2014 to 2019 for mean-adjusted Medicare payment and mean- adjusted charge were submitted for these DRGs.

RESULTS

Mean-adjusted average Medicare payment for DRG 467 decreased by $804.37 (-3.5%) from 2014 to 2019, whereas, that for DRG 468 decreased by $647.33 (-3.6%). The average inflation-adjusted Medicare payment for DRG 467 decreased at a greater rate during the study period, compared to that for DRG 468 (P = .02).

CONCLUSION

The decline in reimbursement for DRGs 467 and 468 reveals decreasing incentives for revision TJA hospitalizations. Further research should assess the efficacy of current Medicare payment algorithms and identify modifications which may provide for fair hospital level reimbursements.

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients

BACKGROUND

Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.

METHODS

All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.

RESULTS

Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.

CONCLUSION

Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

Are We Working Harder for Less Pay? A Survey of Medicare Reimbursement for Hand and Upper Extremity Surgery

BACKGROUND

Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures.

METHODS

The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated.

RESULTS

Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (>3 parts, 21 percent increase; >2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most.

CONCLUSIONS

From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.