Large Variation in Listed Chargemaster Price for Total Joint Arthroplasty Among Top Orthopaedic Hospitals in the United States.

BACKGROUND: Chargemasters are lists of all services offered by a hospital and their associated cost. This study analyzes chargemaster data to determine price differences among different hospitals for total joint arthroplasty. METHODS: In May 2020, the chargemaster data for highly rated orthopaedic hospitals were accessed, and the diagnostic-related group (DRG) codes related to primary and revision total joint arthroplasty were analyzed (DRGs 466, 467, 468, 469, and 470). The prices listed for each hospital were averaged, and descriptive statistics were calculated. Furthermore, Medicare reimbursement was collected. A subanalysis was performed to determine relationships between geographic and demographic information. RESULTS: The median price for a major hip or knee joint arthroplasty without complications was $68,016 (range: $39,927 to $195,264). The median price of a revision of hip or knee arthroplasty without complications was $90,966 (range: $58,967 to $247,715). The cost of living in the city in which the hospitals are located was weakly correlated with procedure pricing, whereas the median income had no notable relationship to chargemaster pricing. CONCLUSION: The published cost of DRG codes in arthroplasty is widely variable among the top 20 US orthopaedic hospitals, with little correlation to the cost of living or median income of the area.

The Current Relationship Between Surgeon Reimbursement and Patient Complexity in Arthroplasty-A Risk-Payment Analysis of All Primary Joint Replacements Billed to Medicare in 2019.

BACKGROUND: The purpose of this study was to assess surgeon reimbursement among total joint arthroplasty (TJA) patients who had differing risk profiles within the Medicare population. METHODS: The "2019 Medicare Physician and Other Provider" file was utilized. In 2019, 441,584 primary total hip and knee arthroplasty procedures were billed to Medicare Part B. All episodes were included. Patient demographics and comorbidity profiles were collected for all patients. Additionally, mean patient hierarchal condition category (HCC) risk scores and physician reimbursements were collected. All procedure episodes were split into 2 cohorts; those with an HCC risk score of 1.5 or greater, and those with patient HCC risk scores less than 1.5. Variables were averaged for each cohort and compared. RESULTS: The mean reimbursement across all procedures was $1,068.03. For the sicker patient cohort with a mean HCC risk score of 1.5 or greater, there was a significantly higher rate of all comorbidities compared to the cohort with HCC risk score under 1.5. The mean payment across the sicker cohort was $1,059.21, while the mean payment among the cohort with HCC risk score under 1.5 was 1,073.32 (P = .032). CONCLUSION: This study demonstrates that for Medicare patients undergoing primary TJA in 2019, the mean surgeon reimbursement was lower for primary TJA among sick patients in comparison to their healthier counterparts, although it is difficult to ascertain the impact of this discrepancy. As alternative payment models continue to undergo evaluation and development, these data will be important for the potential advancement of more equitable reimbursement models in arthroplasty care, specifically regarding surgeon reimbursement and possible risk adjustment within such models.

Publicly Available Pricing Information for Orthopaedic Upper Extremity Procedures in the United States Lacks Transparency and Consistency Between Major Hospitals.

Purpose: The purpose of this study was to assess the price variation of various Medicare severity diagnosis-related group codes for orthopaedic upper extremity procedures for the top 20 orthopaedic hospitals using chargemaster price listings from each hospital. Methods: The top 20 orthopaedic hospitals in the United States were determined by querying the U.S. News and World Report's 2020 orthopaedic hospital ranking. This report ranks orthopaedic hospitals according to 4 major domains: outcomes, structure, process/expert opinion, and patient experience. Chargemaster data for the top 20 orthopaedic hospitals was compiled from their websites. Five DRG codes that represented orthopaedic upper extremity procedures were selected, and the pricing information for each was extracted from hospital chargemasters. The median income and cost-of-living index were also compiled for the county that each hospital is located in so that pricing data could be compared to economic measures through regression analysis. Results: Of the top 20 orthopaedic hospitals, 18 had publicly available pricing information in DRG format on their websites. The DRG code with the highest pricing variability was Hand Injury Procedures (DRG 906; range, $12,832-$253,633). The procedure with the least pricing variability was Hand or Wrist Procedures (DRG 514; range, $24,533-$128,403). Additionally, only the cost of living index was a statistically significant predictor of procedure pricing with a weak correlation. Conclusion: Hospital chargemaster listings are lacking in 2 major areas: true price transparency and standardization/consistency between hospitals. Chargemaster data are often difficult to find, confusing to patients, and inaccurate. Additionally, the price range for a single DRG code can also vary substantially depending on the hospital. It is possible that hospitals located in areas with high costs of living and median incomes would charge higher prices, but these factors were not found to support this hypothesis.

Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model.

BACKGROUND: Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty. METHODS: A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision. RESULTS: Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective. CONCLUSIONS: A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.

A Comprehensive Analysis of Medicare Reimbursement to Physicians for Common Arthroscopic Procedures: Adjusted Reimbursement Has Fallen Nearly 30% From 2000 to 2019.

PURPOSE: To analyze and objectively measure the trends in inflation-adjusted Medicare reimbursement rates for the 20 most commonly performed orthopaedic arthroscopic surgical procedures from 2000 to 2019. METHODS: The Centers for Medicare & Medicaid Services website was used to find the top 20 most commonly performed arthroscopic procedures using the Public Use File data file for calendar year 2017. By use of the Physician Fee Schedule Look-Up Tool, national reimbursement averages were calculated from 2000-2019 and data were analyzed. Averages were adjusted for inflation using the Consumer Price Index. Current Procedural Terminology codes that did not exist in 2000 were unable to be analyzed in this study. RESULTS: When adjusted for inflation, Medicare reimbursement for the 20 most commonly performed arthroscopic procedures from 2000-2019 has decreased substantially (-29.81%). The mean Medicare reimbursement to physicians was $906 in 2000 and $632 in 2019. During this same period, the annual change in the adjusted mean reimbursement rate for all included arthroscopic procedures was -1.8% whereas the average compound annual growth rate was -1.9%. CONCLUSIONS: This study shows that when adjusted for inflation, Medicare reimbursement to physicians has decreased by nearly 30% during the past 20 years for the most common arthroscopic procedures. CLINICAL RELEVANCE: This analysis will give orthopaedic surgeons and hospital administrators a better understanding of the financial trends surrounding one of the fastest-growing techniques in surgery. Additionally, these financial-trend data will be increasingly important as the population in the United States continues to age and new payment models are introduced.

Can a Convolutional Neural Network Classify Knee Osteoarthritis on Plain Radiographs as Accurately as Fellowship-Trained Knee Arthroplasty Surgeons?

BACKGROUND: Osteoarthritis (OA) is the leading cause of disability among adults in the United States. As the diagnosis is based on the accurate interpretation of knee radiographs, use of a convolutional neural network (CNN) to grade OA severity has the potential to significantly reduce variability. METHODS: Knee radiographs from consecutive patients presenting to a large academic arthroplasty practice were obtained retrospectively. These images were rated by 4 fellowship-trained knee arthroplasty surgeons using the International Knee Documentation Committee (IKDC) scoring system. The intraclass correlation coefficient (ICC) for surgeons alone and surgeons with a CNN that was trained using 4755 separate images were compared. RESULTS: Two hundred eighty-eight posteroanterior flexion knee radiographs (576 knees) were reviewed; 131 knees were removed due to poor quality or prior TKA. Each remaining knee was rated by 4 blinded surgeons for a total of 1780 human knee ratings. The ICC among the 4 surgeons for all possible IKDC grades was 0.703 (95% confidence interval [CI] 0.667-0.737). The ICC for the 4 surgeons and the trained CNN was 0.685 (95% CI 0.65-0.719). For IKDC D vs any other rating, the ICC of the 4 surgeons was 0.713 (95% CI 0.678-0.746), and the ICC of 4 surgeons and CNN was 0.697 (95% CI 0.663-0.73). CONCLUSIONS: A CNN can identify and classify knee OA as accurately as a fellowship-trained arthroplasty surgeon. This technology has the potential to reduce variability in the diagnosis and treatment of knee OA.

Costs of open, arthroscopic and combined surgery for developmental dysplasia of the hip.

A variety of options exist for management of patients with developmental dysplasia of the hip (DDH). Most studies to date have focused on clinical outcomes; however, there are currently no data on comparative cost of these techniques. The purpose of this study was to evaluate in-hospital costs between patients managed with periacetabular osteotomy, hip arthroscopy or a combination for DDH. One hundred and nine patients were included: 35 PAO + HA, 32 PAO and 42 HA. There were no significant differences in the demographic parameters. Operative times were significantly different between groups with a mean of 52 min for PAO, 100 min for HA and 155 min for PAO + HA, (P < 0.001). Total direct medical costs were calculated and adjusted to nationally representative unit costs in 2017 inflation-adjusted dollars. Total in-hospital costs were significantly different between each of the three treatment groups. PAO + HA was the most expensive with a median of $21 852, followed by PAO with a median of $15 124, followed by HA with a median of $11 582 (P < 0.001). There was a significant difference between outpatient median costs of $11 385 compared with $24 320 for inpatients (P < 0.001). Procedures with greater complexity were more expensive. However, a change from outpatient to inpatient status with HA moved that group from the least expensive to similar to PAO and PAO + HA. These data provide an important complement to clinical outcomes reports as surgeons and policymakers aim to provide optimal value.

Surgeon Personal Protection: An Underappreciated Benefit of Positive-pressure Exhaust Suits.

BACKGROUND: Positive-pressure exhaust suits cost more than standard surgical gowns, and recent evidence suggests that they do not decrease infection risk. As a result, some hospitals and surgeons have abandoned positive-pressure exhaust suits in favor of less expensive alternatives. We propose that in addition to their original purpose of decreasing infection rates, positive-pressure exhaust suits may also improve personal protection for the surgeon and assistants, perhaps justifying their added costs. QUESTIONS/PURPOSES: (1) Do positive-pressure exhaust suits decrease exposure to particulate matter during TKA? (2) What areas covered by gowning systems are at risk of exposure to particulate matter? METHODS: Three surgical gowning systems were tested: (1) surgical gown, face mask, surgical skull cap, protective eyewear; (2) surgical gown, face mask, surgical protective hood, protective eyewear; and (3) positive-pressure exhaust suit. For each procedure, a cadaver knee was injected intraarticularly and intraosseously with a 5-µm fluorescent powder mixed with water (1 g/10 mL). After gowning in the standard sterile fashion, the primary surgeon and two assistants performed two TKAs with each gowning system for a total of six TKAs. After each procedure, three independent observers graded skin exposure of each surgical participant under ultraviolet light using a standardized scale from 0 (no exposure) to 4 (gross exposure). Statistical analysis was performed using Friedman's and Nemenyi tests. The interrater reliability for the independent observers was also calculated. RESULTS: The positive-pressure exhaust suits had less surgeon and assistant exposure compared with other systems (p < 0.001). The median overall exposure grade for each gowning system was 4 for System 1 (range, 3-4), 2.5 for System 2 (range, 2-3), and 0 for System 3 (range, 0-0). In pairwise comparisons between gowning systems, the positive-pressure exhaust suits had less exposure than gowning System 1 (difference of medians: 4, p < 0.001) and gowning System 2 (difference of medians: 2.5, p = 0.038). There was no difference found in exposure between Systems 1 and 2 (difference of medians: 1.5, p = 0.330). When gowning Systems 1 and 2 were removed, particulate matter was found in places that were covered such as the surgeon's beard, lips, inside the nostrils, behind the protective eyewear around the surgeon's eye, and in both eyebrows and eyelashes. CONCLUSIONS: The positive-pressure exhaust suits provided greater personal protection with each procedure than the other two gowning systems. CLINICAL RELEVANCE: With conventional gowns, particulate matter was found in the surgeon's eyelashes, under the face mask around the mouth, and inside the nostrils. Despite recent evidence that certain types of positive-pressure exhaust suits may not decrease infection, there is a clear benefit of surgeon protection from potentially infectious and harmful patient substances. Despite their added costs, hospitals and surgeons should weigh this protective benefit when considering the use of positive-pressure exhaust suits.