Wide variability in the cost and quality of health care in the US has led some to describe our system as “uniquely inefficient.” Consequently, we continue to study variability intensely, especially in the realm of joint arthroplasty. In the June 3, 2020 issue of The Journal, Schilling et al. elegantly analyze the variations in 90-day episode payments made by Medicare Part A for total knee arthroplasty (TKA) from 2014 to 2016. In so doing, they provide a snapshot of hospital cost performance and, just as importantly, they offer a methodology by which to measure future hospital-level cost performance with this very popular surgery.
The authors reviewed >700,000 TKAs in the Medicare population at a time prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model, and they ranked >3,200 hospitals within 9 US regions to determine cost performance. Schilling et al. found that during those 3 years, the mean Medicare episode payment for TKA decreased significantly, due almost entirely to a >$1,500 per-case decrease in post-acute care payments, which included lower costs for skilled nursing facilities and inpatient rehabilitation. Also decreasing during that same period were length of hospital stay and 90-day readmission rates.
These findings highlight the improvements in care and cost efficiency that were occurring even before implementation of the CJR. In a Commentary on this study, Susan Odum, PhD suggests that “the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI [Bundled Payments for Care Improvement] program,” an alternative payment model that Medicare rolled out beginning in 2013.
On the other hand, the authors also reveal a persistently high degree of variability in episode payments and resource utilization both across and within geographic regions. This strongly suggests the possibility of further improvement. Regardless of which, if any, alternative payment model we participate in, everyone in the orthopaedic community should think about how to become more efficient in our delivery of musculoskeletal care. And this study provides a conceptual framework and benchmarks for identifying where the room for improvement is.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”
Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.
This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).
Specifically, on the clinical side, Farley et al. found the following:
- A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
- A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
- A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)
Here are the findings from the resource-utilization side:
- A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”
The most common complication arthroplasty surgeons worry about after total knee arthroplasty (TKA) is stiffness, which occurs in a reported 15.98% of cases.1 The notion of TKA patients doing their postoperative physical therapy (PT) on their own at home with a “virtual avatar” gives me pause because it might increase the risk of stiffness. However, if patients could save money, make satisfactory progress in the comfort of their own home, and not experience undue knee stiffness, virtual PT technology would be worth it.
In the January 15, 2020 issue of The Journal, Bettger et al. report on a randomized controlled trial that compared virtual to traditional PT after TKA. The authors hypothesized that virtual PT would cost less and would be clinically noninferior to traditional PT. The FDA-approved Virtual Exercise Rehabilitation Assistant (VERA) studied in this trial uses 3-D technology to track patient movement and an avatar (digitally simulated coach) to assist patients through PT exercises. Virtual PT technology like this not only has the potential to reduce costs (particularly travel costs incurred by patients who live in rural areas), but also to help address current and expected therapist shortages.
There were 143 patients in the virtual PT group and 144 in the traditional PT group. Patients randomized to virtual PT had the technology set up in their home prior to surgery. In addition to avatar-assisted home exercises, virtual PT patients had weekly “video visits” with a human therapist.
Bettger et al. found the median 12-week costs for virtual and traditional PT to be $1,050 and $2,805, respectively. Additionally, at 6 weeks, virtual PT was found to be noninferior to traditional PT in terms of patient outcome measures, knee range of motion, and gait speed. At 12 weeks, virtual PT was found to be noninferior to usual care in terms of pain and hospital readmissions.
I am relieved that virtual PT has the potential to provide cost savings, without apparently increasing the risk of knee stiffness. The cost savings and at-home convenience may be especially important for elderly TKA patients who are living on a fixed income and for whom transportation issues are often vexing. I hope technology like VERA continues to contribute to improved patient satisfaction and easier access to PT.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
- Can administrative data be used to analyze complications following total joint arthroplasty? Clair AJ, et al. J Arthroplasty, 2015;30(9 Suppl):17-20. http://dx.doi.org/10.1016/j.arth.2015.01.060
At the risk of economic oversimplification, it is difficult to sustainably provide a service when payment for it is less than the cost to perform it. But that is one reality exposed by Hevesi et al. in the May 15, 2019 issue of The Journal. Using National Inpatient Sample and ACS-NSQIP data, the authors compared the average costs and 30-day complication rates for revision total hip arthroplasties (THAs) performed for 3 different indications—fractures, wear/loosening, and instability—at both a local and national level. They found that the average hospitalization costs associated with a revision THA related to a fracture were 33% to 48% higher (p < 0.001) than the cost of revision THAs related to wear or instability.
However, the authors emphasize that all 3 of these indications for revision THA are reimbursed at the same rate based on Medicare Diagnosis-Related Group (DRG) codes. DRGs take into account patient comorbidities to determine reimbursement levels—but they do not adjust payments for THA revision according to indication. Hevesi et al. note that the only DRG reimbursement level that would cover the average cost of a revision THA for a fracture would be one performed on a patient with severe medical comorbidities or a major complication. Not surprisingly, patients who underwent a revision THA to treat a fracture were found to have a higher age and more medical comorbidities than those undergoing a revision for wear or instability.
The authors use this data to make a very compelling case that DRGs for revision THA should be changed so they are indication-specific, taking into account the underlying reason for the revision. They observe that “a DRG scheme that does not distinguish between indications for revision THA sets the stage for disincentivizing the care of fracture patients and incentivizing referrals to other facilities.” Those “other facilities” usually end up being large tertiary-care centers, which the authors claim “perform a higher percentage of the costlier revision THA indications.”
This problem of reimbursement inequality is not unique to revision THAs and requires further investigation in many fields. Unless “the system” addresses these subtle but important differences, tertiary referral centers may be inundated with patients who need procedures that cost more to perform than the institutions receive in reimbursement—an unsustainable scenario.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Concerns have arisen that the implementation of value-based, alternative payment models pegged to “bundled” episodes of care and/or patient outcomes may make it harder for a subset of patients to access the care they need. Specifically, some surgeons may be apprehensive to treat patients who have substantial medical comorbidities or socioeconomic situations that increase their risk of postsurgical complications and poor outcomes, because these alternative payment models often financially penalize physicians and hospitals for the cost of suboptimal results. The study by Shau et al. in the December 5, 2018 issue of The Journal provides data that sharpens the horns of this dilemma.
The authors used the National Readmissions Database to perform a propensity-score-matched comparison between >5,300 patients with Medicaid payer status who underwent a primary total hip arthroplasty (THA) and an equal number of patients with other types of insurance who also underwent primary THA. Shau et al. found that Medicaid-covered THA patients had significantly increased overall readmission rates (28.8% vs 21%, p <0.001, relative risk=1.37), mean length of stay (4.5 vs 3.3 days, p <0.0001), and mean total cost of care ($71,110 vs $65,309, p <0.0001), relative to the other group. These results strongly suggest that Medicaid payer status is an independent factor associated with increased resource utilization after total hip arthroplasty.
These findings can be viewed from a couple of different perspectives. First, from a preventive standpoint, surgeons and healthcare systems providing THA for Medicaid patients may need to spend more time preoperatively optimizing these patients (both physically and psychosocially) to decrease their postoperative resource burden and increase the likelihood of a good clinical outcome. Second, these results are further proof that any fair and effective alternative payment model needs to take into consideration factors such as Medicaid payer status and patient comorbidities. If they do not, such models will actually throw access barriers in front of patients in this demographic because providers may feel that caring for them increases the likelihood of being penalized financially.
Both perspectives are valid, so Medicaid payer status is a crucial factor to consider as alternative payment programs move forward. Nowadays, controlling costs is an important goal of any healthcare delivery system, but it must not lead to unintended discrimination in patient access to care. As we create further alternative payment models and refine existing ones, we must be careful not to prioritize cost cutting ahead of equitable patient access.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Surgical treatment for knee osteoarthritis (OA) has become increasingly common. The many people who have damage to only one part of their joint (unicompartmental knee OA) are faced with three options—total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or nonsurgical treatment. A study by Kazarian et al. in the October 3, 2018 issue of The Journal estimates the lifetime cost-effectiveness for those three options in patients from 40 to 90 years of age.
The authors used sophisticated computer modeling to estimate both direct costs (those related to medical/surgical care) and indirect costs (such as missed workdays) of the three options as a function of patient age at the time of treatment initiation. Here are the key findings:
- The surgical treatments were less expensive and provided patients from 40 to 69 years of age with a greater number of quality-adjusted life years (QALYs) than nonsurgical treatment.
- In patients 70 to 90 years of age, surgical treatments were still cost-effective compared with nonsurgical treatment, albeit less so than in younger patients. In this older age group, “cost-effectiveness ratios” of surgical treatment remained below a “willingness to-pay” threshold of $50,000 per QALY.
- When the two surgical treatments were compared to one another, UKA beat TKA decisively in cost-effectiveness among patients of any age.
After crunching more numbers, Kazarian et al. estimated that, by 2020, if all of the patients with unicompartmental knee OA who were candidates for UKA or TKA (a projected total of 120,000 to 210,000 people) received UKA, “it would lead to a lifetime cost savings of $987 million to $1.5 billion.
From these findings, the authors conclude that patients with unicompartmental knee OA should receive surgical treatment, preferably UKA, instead of nonsurgical treatment until the age of 70 years. After that age, all three options are reasonable from a cost-effectiveness perspective.
But perhaps the most important thing to remember about these findings is that they add information to—but should not replace—clinical decision-making based on complete and open communication between doctor and patient.
The intended goals of requiring electronic medical record (EMR) systems in all hospitals and clinics were rational and, for the most part, patient-centered. EMRs have prevented large numbers of potentially serious medication errors, served as a secure means of making laboratory and imaging data readily available to surgeons, and have provided an efficient mode of communication among members of health care teams.
Unfortunately, the design of most, if not all, EMR systems is focused on coding and billing, not on the doctor-patient interaction during the all-important face-to-face clinic visit. This has had the unintended consequence of requiring dense, protracted documentation of care interactions that seems to de-emphasize the most important part of the EMR entry: the physician’s thought process and treatment plan.
In the September 19, 2018 edition of The Journal, Scott et al. provide us with a unique cost-and-productivity view into the impact that implementing an EMR had within an outpatient orthopaedic clinic. During the first 6 months after a new EMR was launched, total labor costs increased, driven by attending surgeons and medical assistants spending increased time documenting visits. Although the total per-encounter cost returned to baseline levels after 6 months, more time was spent documenting encounters and less time was spent interacting with patients than before EMR implementation. So, even after a return to normal clinic “productivity” after the 6-month learning period, the price paid for increased time spent documenting on the new EMR was decreased provider-patient “face time.”
In my opinion, it is essential that we work to remedy this deficiency. Personally, I do not use EMR-provided templates for documenting physical exam findings, imaging study results, and treatment plans. Instead, I engage with the patient during the visit and make detailed notes in the EMR after the patient leaves. This probably results in “under-billing” for my services, but I am willing to pay that price to increase the value of the visit for the patient—and for my colleagues who may review my notes.
The study by Scott et al. is a necessary first step in understanding EMR ramifications in orthopaedics, but our community needs more broad-based research to further delve into the full impact of EMRs on patient care, patient satisfaction, and cost. Toward that end, the Orthopaedic Research and Education Foundation (OREF) recently extended until September 28, 2018 the deadline for grant proposals to investigate the impact of EMR regulations on the patient-physician relationship. We must continue to address this apparent problem to improve patient care, which was the goal of EMRs in the first place.
Marc Swiontkowski, MD
Annual volume projections for total joint arthroplasty (TJA) have been cited frequently and applied broadly, often to estimate future costs. But with a slowdown in the growth of the annual incidence of total knee arthroplasty (TKA), updated projections are needed, and that’s what Sloan et al. provide in the September 5, 2018 issue of JBJS.
Using the National Inpatient Sample to obtain TJA incidence data, the authors first analyzed the volume of primary TJA procedures performed from 2000 to 2014. They then performed regression analyses to project future volumes of TJA procedures. Here are the numbers based on the 2000-to-2014 data:
- Primary total hip arthroplasty (THA) is projected to grow 71%, to 635,000 annual procedures by 2030.
- Primary TKA is projected to grow 85%, to 1.26 million annual procedures by 2030.
However, the TKA procedure growth rate has slowed in recent years, and models based on 2008-to-2014 data project growth to only 935,000 annual TKAs by 2030—325,000 fewer procedures relative to the 2000-to-2014 models.
Earlier studies, notably one by Kurtz et al. in 2007, obviously could not account for the reduced growth rate in TKA after 2008. A 2008 analysis by Wilson et al., based on the Kurtz et al. data, estimated that annual Medicare expenditures on TJA procedures would climb from $5 billion in 2006 to $50 billion in 2030. “Using our projections,” say Sloan et al., “we predict that Medicare expenditures on these procedures in 2030 will be less than half of that predicted by Wilson et al.”
These findings lend credence to the authors’ observation that “it is imperative that projections of orthopaedic procedures be regularly evaluated and updated to reflect current rates.”
While patients are sometimes concerned that resident involvement in their surgical case might lead to untoward outcomes, the article by Neuwirth et al. in the January 17, 2018 edition of JBJS provides data to alleviate some of those fears. The authors used the NSQIP database to evaluate whether resident involvement with the surgical treatment of intertrochanteric hip fractures resulted in increased 30-day mortality or morbidity, compared to similar cases in which a resident did not participate. The study found no differences in either 30-day mortality or severe morbidity between cases that involved a resident and those that did not. However, cases involving residents did have significantly longer operative times, lengths of hospital stay, and times from operation to discharge.
These findings, which are similar to those of studies performed in other orthopaedic subspecialties, provide both relief and unease. Surgical education is built on apprenticeship and increasing autonomy throughout residency, so it is comforting that cases of this fracture type involving residents do not increase patient risks of mortality or severe morbidity. The findings suggest that residents are being appropriately supervised and given responsibilities that are commensurate with their level of training.
However, this study also shows that there is a price to be paid for resident education. Any “extra” time that a patient spends in the operating room or the hospital has associated costs to the health care system. Neuwirth et al. show that cases involving residents had a five times greater incidence of lasting more than 90 minutes and an average operative time that was more than 20 minutes longer, compared to cases not involving residents. If one were to extrapolate those added time-related costs across all intertrochanteric fracture surgeries performed in the US each year, the total added annual costs could be astronomical.
My concern is that as we move further toward value-based care, justifying these resident-training costs will become more challenging. Should resident involvement in a case be stopped after a certain amount of operative time? How close should a resident’s surgical time be to that of an attending surgeon’s by the time of graduation? What is the actual cost of resident training per surgical case? This study prompts these and similar difficult questions.
Education, like most investments, requires both time and money in order to pay dividends. While everyone can agree that it is important to train our future surgeons appropriately, there will likely be increasing pressure to do so in the most cost-efficient manner possible.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media