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Several patient factors associated with increased hospital costs for TKA
Researchers found no association between differences in costs and BMI, sex and race.
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Older patients undergoing total knee arthroplasty who had higher American Society of Anesthesiologists classifications and met Medicare Major Complications/Comorbid Conditions criteria showed an increase in hospital costs, according to a study.
“There are identifiable preoperative risk factors that suggest certain [total knee arthroplasty] TKA patients will be financially favorable or detrimental under the [Bundled Payments for Care Improvement Initiative] BPCI. R. Carter Clement, MD, MBA, chief resident in orthopedic surgery at the University of North Carolina at Chapel Hill, told Orthopedics Today. “Namely, older patients, those with elevated [American Society of Anesthesiologists] ASA class and those at high-risk for major medical complications.”
Increase in costs
Clement and his colleagues determined variable costs for operative hospitalization and any unplanned readmissions within 30 days of discharge for 941 patients (69% were women) undergoing elective unilateral primary TKA.
Results showed an association between increased age, ASA class and the presence of a Medicare Major Complications/Comorbid Conditions (MCC) modifier with increased costs. Variable costs increased by $57 per year of life in patients older than 65 years, $729 per ASA class beyond one and $3,122 for patients with MCC criteria, according to regression coefficients of multivariate analysis. However, BMI, sex and race were not associated with differences in costs.
“We were surprised increased BMI was not statistically significantly associated with increased costs among TKA patients,” Clement said. “Furthermore, BMI was associated with cost among [total hip arthroplasty] THA patients in our recent Journal of Arthroplasty paper. This possibility deserves further research.”
Risk adjustment
Clement noted these results highlight the importance of risk-adjusting bundled payments for these factors.
“If CMS does not risk-adjust bundled payments for these factors, Medicare reimbursement will create unintended financial incentives that could restrict access to care for certain patients,” he said.
Furthermore, the Comprehensive Care for Joint Replacement model covers a longer episode of care, which may increase the strength of such financial incentives. He added the current methodologies are “not enough risk adjustment to prevent unintended financial incentives.”
“We need to learn much about preoperative risk factors for high costs of care,” Clement said. “I would hypothesize that it is more expensive to provide TKA or THA for patients with comorbidities like [end stage renal disease] ESRD, advanced hepatic disease or hemophilia. As an orthopedic community, we need to prove and quantify this additional cost, and, if it is real, CMS and insurance companies should provide higher bundled payments for these patients accordingly.” – by Casey Tingle
- Reference:
- Clement RC, et al. Orthopedics. 2016;doi:10.3928/01477447-20160623-04.
- For more information:
- R. Carter Clement, MD, MBA, can be reached at University of North Carolina Hospitals, Department of Orthopaedic Surgery, 101 Manning Dr., Chapel Hill, NC 27514; email: carter.clement@gmail.com.
Disclosure: Clement reports no relevant financial disclosures.