Cost analysis and containment in primary total hip arthroplasty

The Relationship Between Hospital Payer Mix and Volume Growth in Total Joint Arthroplasty: A 12-Year Analysis

BACKGROUND

Hospital reimbursement for Medicare/Medicaid/self-pay patients has not kept pace with rising expenses, and even well run efficient organizations struggle to maintain a positive margin on these cases. Therefore, hospitals rely on commercially insured patients to remain economically viable. However, hospitals located in areas with a high Medicare/Medicaid/uninsured population cannot depend on a favorable payer mix for financial sustainability.

METHODS

Using the Statewide Planning and Research Cooperative System database, total joint arthroplasties (TJAs) in New York from 2000 to 2012 were identified. Hospitals were divided into quartiles by volume, with quartile 1 representing the lowest volume hospitals. TJA cases were stratified by primary payer type, and the percentage of each primary payer type was calculated and compared among quartiles.

RESULTS

The highest number of hospitals performing TJAs was 207 in 2000, and the least number of hospitals was in 2012, with only 178 hospitals performing TJA. Despite the decrease in the number of hospitals, the total number of joint arthroplasties increased from 33,036 in 2000 to 62,104 in 2012.

CONCLUSIONS

Our study demonstrates that higher volume hospitals tended to have a more favorable payer mix (less Medicare/Medicaid/self-pay patients). This inequity widened over the 12-year study period. This trend has ethical implications for lower socioeconomic status patients as high-volume centers tend to have superior outcomes compared with low-volume centers. In addition, the lower volume high Medicare/Medicaid/self-pay hospitals are more susceptible to the Center for Medicare and Medicaid Services quality penalties making their economic viability even more tenuous potentially leading to access of care problems for these patients.

Surgeons' knowledge about the costs of orthopaedic implants

PURPOSE. To investigate consultant surgeons' knowledge about the costs of implants for various joint surgeries. METHODS. Questionnaires were distributed to consultant orthopaedic surgeons at 2 hospitals. Respondents were asked to estimate the implant costs of any brand for low-demand and high-demand total hip replacement (THR), total knee replacement (TKR), uni-compartmental knee replacement, arthroscopy shaver blade, total anterior cruciate ligament (ACL) fixation, and meniscal repair. The actual cost of each implant was obtained from the manufacturer. RESULTS. 16 consultant surgeons completed the questionnaires. The respective mean estimated and actual costs for a low-demand THR implant were £1714 (range, £600-3000) and £1448 (range, £985- 2335), with an overestimation of 18.4%. The respective costs for a high-demand THR implant were £2172 (range, £600-6000) and £1737 (range, £1192-2335), with an overestimation of 25%. The respective costs for a TKR implant were £1550 (range, £600-6000) and £1316 (range, £995-1535), with an overestimation of 17.8%. The respective costs for a uni-compartmental knee replacement implant were £1040 (range, £600-2000) and £1296 (range, £698-1470), with an underestimation of 19.7%. The respective costs for an arthroscopy shaver blade were £110 (range, £75-150) and £94 (range, £80-100), with an overestimation of 16.6%. The respective costs for a total ACL fixation implant were £246 (range, £80-500) and £306 (range, £272-335), with an underestimation of 19.4%. The respective costs for a meniscal repair implant were £153 (range, £50-250) and £242 (range, £170-260), with an underestimation of 37%. CONCLUSION. The knowledge among consultant orthopaedic surgeons about implant costs was poor. To reduce implant costs, cooperation between surgeons and hospital managers and measures to increase surgeons' awareness about cost-reduction programmes are needed.

Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review

SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway?

METHOD

Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included.

RESULTS

Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking.

CONCLUSIONS

A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.