In a study now reported in JBJS, Acuña et al. analyzed Medicare reimbursements associated with revision total hip arthroplasty (THA) procedures. After adjusting for inflation, they found that the mean physician fee reimbursement for revision THA due to aseptic complications declined by a mean of 27% for femoral component revision, 27% for acetabular component revision, and 28% for both-component revision from 2002 to 2019. For 2-stage revision due to infection, they found that mean reimbursement fell by 19% and 24% for the explantation and reimplantation stages, respectively.
The total decline in reimbursement for revision THA due to infection ($1,020.64 ± $233.72) was significantly greater than that for revision due to aseptic complications ($580.72 ± $107.22) (p < 0.00001).
Reflecting on their investigation, the authors note:
In light of persistent cost pressures and discussions surrounding the future of total hip arthroplasty reimbursement, our study explores temporal trends in the Centers for Medicare & Medicaid Services (CMS) physician fee schedule for revision THA procedures. Our findings, showing a significantly larger decline for septic revision THA reimbursements compared to their aseptic counterpart, may have important implications for ongoing discussions surrounding the CMS physician fee schedule.”
They conclude in their study that, “continuation of this trend [of decreased reimbursement] could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.”
Click here for the full JBJS report.
A recent OrthoBuzz post on reimbursement for revision TKA can be found here.
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
Revision total hip arthroplasty (THA) is a challenging procedure for many reasons, not the least of which is the risk of aseptic loosening leading to re-revision, especially in patients with severe acetabular defects. Acetabular components made of porous tantalum have a developed a good reputation for lower rates of re-revision, relative to components made of other materials. In the November 21, 2018 issue of The Journal of Bone & Joint Surgery, Solomon et al. bolster the evidence base regarding the success of porous tantalum acetabular components in revision THA.
The authors conducted a single-center prospective cohort study that used radiostereometric analysis (RSA) to accurately measure acetabular component migration in 55 revision THAs that involved a porous tantalum acetabular component. Over a mean follow-up of 4 years, 48 of the 55 components migrated <1 mm, the threshold that, based on previous findings in the literature, the authors defined as predicting later loosening. Five of the 7 components that exceeded the threshold were re-revised for loosening related to patient symptoms.
The RSA data for the 5 components that required re-revision revealed large proximal translations and sagittal rotations that increased over time until re-revision, although the RSA readings revealed that the majority of the migration occurred in the first 6 weeks. Among the components that did not exceed the 1 mm threshold for migration at 2 years, none have been subsequently re-revised for loosening.
The authors also analyzed fixation methods in this cohort. They found that, at 2 years, the median proximal translation of components that used inferior screw fixation was significantly lower than that of components without inferior screw fixation. The take-home messages from this study seem to be as follows:
- Porous tantalum acetabular components really do perform well in revision THA.
- When indicated, inferior screw fixation lowers the risk of component migration.
- Early component migration is a good predictor of long-term component survivorship.