Study projects increasing disparity in charges, reimbursement for total joint surgery

Study projects increasing disparity in charges, reimbursement for total joint surgery

Medicare recipients who become candidates for total hip or total knee replacement in the next decade will likely see their out-of-pocket expenses increase, said the authors of scientific presentation 22 yesterday. Medicare represents the single largest payer for hip and knee arthroplasty in the United States, and its coverage decisions and payments affect not only patients, but also surgeons, hospitals and taxpayers.

Based on their analysis, the authors project an increasing disparity between reimbursement and hospital charges through 2015. “National annual hospital charges for primary total hip arthroplasty (THA) could increase by 340 percent to $17.4 billion, while charges for primary total knee arthroplasty (TKA) may go up 450 percent to $40.8 billion,” said coauthor Kevin Ong, PhD. “Surgical charges for THA are projected to increase by 180 percent to $1.9 billion and TKA will rise 250 percent to $5.1 billion.”

Researchers anticipate a massive demand for revision hip and knee surgeries in the next two decades. The number of hip revisions surgeries is expected to increase by 137 percent, while the number of knee revision surgeries is projected to grow by 601 percent between 2005 and 2030. The economic consequences of this increasing demand for hip and knee replacement surgeries are still unknown.

“Revision hip and knee arthroplasty procedures require significantly greater utilization of hospital resources than primary arthroplasty,” said coauthor Khaled J. Saleh, MD. “Revision procedures result in greater blood loss, a longer operative time, and a longer length of stay in the hospital. In addition, there is an increased likelihood that revision patients will be discharged to extended care facilities.

“The increasing discrepancy between procedural charges and Medicare reimbursements places a substantial financial burden on surgeons and hospitals,” he continued. “Medicare reimbursements for revision THA and TKA only constitute approximately one-third of the associated procedural charges.”

Overall charges for hip and knee arthroplasty procedures are expected to increase 3.7 to 5.2- fold. “This may have enormous impact on hospital and surgeon utilization, especially since Medicare reimbursements average only 32 to 38 percent of the charges per procedure,” added Dr. Ong.

Charges for primary and revision THA and TKA are projected to increase over the next decade for all age and gender groups. Women account for about two-thirds of the overall charges. The distribution of charges by age groups differed depending on the procedure. The most elderly age group (more than 84 years) was estimated to contribute to a substantial proportion of revision THA charges. The youngest eligible Medicare patients (65-69 years) were projected to account for an increasing proportion of charges for all procedures, accounting for as much as 39.4 percent of primary TKA charges in 2015.

The research team included Dr. Ong, Steven M. Kurtz, MD, and Edmund Lau, MS, all of Philadelphia; Fionna Mowat, PhE, of Menlow Park, Cal.; Dr. Saleh of Charlottesville, Va., and Jordana K. Schmier, MA, of Alexandria, Va.

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