Out-of-pocket expenses for ACL reconstruction increased despite decrease in reimbursement
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Published results showed an increase in out-of-pocket expenses for patients undergoing arthroscopic ACL reconstruction despite a decrease in overall payer reimbursement.
“We found that for ACL reconstruction surgery, one of the highestvolume orthopedic surgeries performed in the U.S., out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs,” Shawn G. Anthony, MD, MBA, sports medicine and orthopedic surgeon at Mount Sinai, told Healio. “High-deductible health plans had the highest out-of-pocket patient costs.”
Using the IBM MarketScan Commercial Claims and Encounters database, Anthony and colleagues collected total patient payments and reimbursed claim totals in U.S. dollars among 37,763 patients who underwent outpatient primary arthroscopic ACL reconstruction between 2013 and 2017. Immediate procedure reimbursement, total health care utilization reimbursement and breakdown, and facility-specific reimbursements were considered the outcomes of interest, according to researchers.
Results showed a 4.3% decrease in day-of-surgery reimbursement from $11,536 in 2013 to $11,044 in 2017 as well as a 36% increase in patient out-of-pocket expenses from $1,085 in 2013 to $1,480 in 2017. Researchers found the highest expense for patients was day-of-surgery charges followed by physical therapy and MRI costs. Although total reimbursement for MRI decreased 22.5%, patient out-of-pocket expenses for MRI increased 166%, according to results. When compared with ACL reconstruction performed in an ASC, researchers noted ACL reconstruction performed in an outpatient hospital resulted in a 61% greater day-of-surgery expenditure for payers. However, researchers found a median total patient out-of-pocket savings of $11 for ACL reconstruction performed in an ASC vs. an outpatient hospital.
“Health insurers are cutting reimbursements while requiring that procedures be done in more economic facilities like ambulatory surgery centers, improving their profits but not sharing these cost-saving benefits with patients or providers,” Anthony said.
Perspective
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One of the most devastating injuries in sports is a torn ACL. Athletes must deal with the pain of surgery, endless rehabilitation, the concern of not returning to play and the fear of retearing their graft. Now, the paper by Andrew Carbone, MD, and colleagues opens our eyes to a new challenge that athletes must deal with after an ACL tear, the fear of paying for their treatment.
The study pointed out the concerning trend of declining payer reimbursement and rising out-of-pocket costs for ACL reconstruction. During the 5-year study period from 2013 to 2017, the average reimbursement for ACL reconstruction decreased 4.3%, while the patient’s out-of-pocket expenses increased 36%. Not only has the out-of-pocket expense for the treatment of ACL reconstruction surgery increased, but so have the costs surrounding the surgery, such as for MRIs and physical therapy. During the study period, out-of-pocket cost for an MRI increased 166%, while reimbursement for the scan decreased 22.5%. These trends in out-of-pocket costs may make not only the ACL surgery, but also the tests necessary to make the diagnosis and the therapy required after surgery, cost prohibitive.
The article raises a true concern of whether the current trend of increased out-of-pocket cost will affect athletes’ ability to play the sport they love. Will the worry of paying for surgery lead someone to choose not to participate in a sport? Worse yet, will parents have to decline moving forward with a surgery they feel their child needs simply because they cannot afford the surgery?
More effort needs to be placed in dealing with the skyrocketing out-of-pocket costs of ACL reconstruction. The article mentions bundled payments and moving cases to surgeon-controlled ASCs to help control cost. These are good starts, but further ideas will be necessary to correct the current trend in increasing patient out-of-pocket costs. The real question is: If patients are paying more and physicians are being paid less for ACL surgery, who is benefiting from this situation? The article is a stark reminder of how the economics of medicine could eventually dictate care of ACL tears and foreshadows the future of payments for the treatment of other sports-related injuries.
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