Changes in Total Knee Arthroplasty Utilization since the Implementation of ACA: An Analysis of Patient–Hospital Demographics, Costs, and Charges

Abstract

The Patient Protection and Affordable Care Act (PPACA) formed the Center for Medicare and Medicaid Innovation Center which has implemented experimental reimbursement models targeted at high-demand procedures to improve care quality. However, the effect of health care reform on total knee arthroplasty (TKA) procedures has not been explored. This study explores patient–hospital level demographics, inpatient costs, and charges related to TKA procedures between 2009 and 2015. The National Inpatient Sample database was utilized to identify patients who received primary TKA between January 2009 and October 2015 (4,283,387 cases). Categorical, continuous, and ordinal data were analyzed using chi-square/Fisher's exact test, t-test/analysis of variance, or Kruskal–Wallis' test, respectively. There was an increase in proportion of TKA recipients belonging to minority groups and the lowest quartile of median income (p < 0.05). There was a 1.9% increase in recipients using Medicaid as a primary payor and volume shifts from urban nonteaching toward urban teaching hospitals. There was a reduction in mean length of stay and mean inpatient costs. There were increases in hospital charges, but reductions in rates of inpatient mortality, and other postoperative complications. TKA procedures remain the most common surgical procedure; therefore, our study assessed national trends to capture the effect of PPACA. We found an increasing proportion of TKA recipients belonging to minority and low-income groups, volume shifts to urban teaching hospitals, and lower costs of care. These findings may be useful in objectively critiquing the effects of PPACA on TKA-related care.

Keywords

total knee arthroplasty - TKA - Affordable Care Act - health care - socioeconomics - Patient Protection and Affordable Care Act

• Reference

• 1 Obama B. United States health care reform: progress to date and next steps. JAMA 2016; 316 (05) 525-532
• 2 Delanois RE, Gwam CU, Mistry JB. , et al. Does gender influence how patients rate their patient experience after total hip arthroplasty?. Hip Int 2018; 28 (01) 40-43
• 3 Gwam C, Mistry JB, Piuzzi N. , et al. What influences how patients with depression rate hospital stay after total joint arthroplasty?. Surg Technol Int 2017; 30: 373-378
• 4 Chughtai M, Patel NK, Gwam CU. , et al. Do Press Ganey scores correlate with total knee arthroplasty-specific outcome questionnaires in postsurgical patients?. J Arthroplasty 2017; 32 (9S): S109-S112
• 5 Giovannelli J, Lucia KW, Corlette S. Implementing the Affordable Care Act: revisiting the ACA's essential health benefits requirements. Issue Brief (Commonw Fund) 2014; 28: 1-10
• 6 Etcheson JI, George NE, Gwam CU. , et al. Trends in total hip arthroplasty under the Patient Protection and Affordable Care Act: a national database analysis between 2008 and 2015. Orthopedics 2018; 41 (04) e534-e540
• 7 McKenna RM, Langellier BA, Alcalá HE, Roby DH, Grande DT, Ortega AN. The Affordable Care Act attenuates financial strain according to poverty level. Inquiry 2018; 55: 46958018790164
• 8 Eguia E, Cobb AN, Kothari AN. , et al. Impact of the Affordable Care Act (ACA) Medicaid expansion on cancer admissions and surgeries. Ann Surg 2018; 268 (04) 584-590
• 9 Mistry JB, Gwam C, Delanois RE. Medicaid and state-based programs. Semin Arthroplasty 2016; 27: 196-200
• 10 Siddiqi A, White PB, Mistry JB. , et al. Effect of bundled payments and health care reform as alternative payment models in total joint arthroplasty: a clinical review. J Arthroplasty 2017; 32 (08) 2590-2597
• 11 Gwam CU, Mistry JB, Mohamed N. , et al. Does age influence how patients rate their experience of care after total knee arthroplasty?. J Knee Surg 2017; 30 (07) 647-651
• 12 Kivlahan C, Orlowski JM, Pearce J, Walradt J, Baker M, Kirch DG. Taking risk: early results from teaching hospitals' participation in the Center for Medicare and Medicaid Innovation Bundled Payments for Care Improvement Initiative. Acad Med 2016; 91 (07) 936-942
• 13 Burwell SM. Setting value-based payment goals--HHS efforts to improve U.S. health care. N Engl J Med 2015; 372 (10) 897-899
• 14 Overview 2017. Available at: https://www.cms.gov/About-CMS/Agency-information/History/ . Accessed December 13, 2017
• 15 About the CMS Innovation Center|Center for Medicare & Medicaid Innovation. Available at: https://innovation.cms.gov/About/index.html Accessed September 10, 2018
• 16 CMS. Bundled Payments for Care Improvement: Overview and Basic Parameters CMS Center for Medicare and Medicaid Innovation (CMMI) Bundled Payments for Care Improvement Team 2014. Available at: https://innovation.cms.gov/Files/slides/BPCI-Overview2-4.pdf . Accessed August 13, 2017
• 17 Delanois RE, Gwam CU, Cherian JJ. , et al. Global budget revenue on a single institution's costs and outcomes in patients undergoing total hip arthroplasty. J Arthroplasty 2018; 33 (07) 2043-2046
• 18 Centers for Clinical Standards and Quality, Centers for Medicare & Medicaid Services. CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Baltimore, MD: US Department of Health and Human Services; 2016. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/2017-cms-mdp-annual-report.pdf . Accessed July 5, 2018
• 19 HEALTHCARE COST AND UTILIZATION PROJECT (HCUP) RECOMMENDATIONS FOR REPORTING TRENDS USING ICD-9-CM AND ICD-10-CM/PCS DATA n.d. Available at: https://www.hcup-us.ahrq.gov/datainnovations/HCUP_RecomForReportingTrends_070517.pdf . Accessed July 17, 2018
• 20 Steiner C, Elixhauser A, Schnaier J. The healthcare cost and utilization project: an overview. Eff Clin Pract 2002; 5 (03) 143-151
• 21 Riley GF. Administrative and claims records as sources of health care cost data. Med Care 2009; 47 (07) (Suppl. 01) S51-S55
• 22 HCUP. HCUP-US NIS Overview 2015. Available at: https://www.hcup-us.ahrq.gov/nisoverview.jsp . Accessed April 3, 2017
• 23 Ahern TP, Bosco JL, Silliman RA. , et al. Potential misinterpretations caused by collapsing upper categories of comorbidity indices: an illustration from a cohort of older breast cancer survivors. Clin Epidemiol 2009; 1: 93-100
• 24 Fraccaro P, Kontopantelis E, Sperrin M. , et al. Predicting mortality from change-over-time in the Charlson comorbidity index: a retrospective cohort study in a data-intensive UK health system. Medicine (Baltimore) 2016; 95 (43) e4973
• 25 Yang C-C, Fong Y, Lin L-C. , et al. The age-adjusted Charlson comorbidity index is a better predictor of survival in operated lung cancer patients than the Charlson and Elixhauser comorbidity indices. Eur J Cardiothorac Surg 2018; 53 (01) 235-240
• 26 HCUP NIS Description of Data Elements. Healthcare Cost and Utilization Project (HCUP) NIS Notes 2008. Available at: https://www.hcup-us.ahrq.gov/db/vars/zipinc_qrtl/nisnote.jsp . Accessed April 3, 2017
• 27 CPI Inflation Calculator n.d. Available at: https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=10.00&year1=201501&year2=201801 . Accessed July 31, 2018
• 28 AHRQ Quality Indicators™ Patient Safety Indicators Other AHRQ Quality Indicators n.d. Available at: https://www.qualityindicators.ahrq.gov/modules/psi_resources.aspx . Accessed July 31, 2018
• 29 Sharpe D. Your chi-square test is statistically significant: now what?. Practical Assessment, Research Evaluation 2015; 20 (08) 1-10
• 30 Siqueira MBP, Chughtai M, Khlopas A. , et al. Does gender influence how patients rate their patient experience after total knee arthroplasty?. J Knee Surg 2017; 30 (07) 634-638
• 31 MacLean C. Value-based purchasing for osteoarthritis and total knee arthroplasty: what role for patient-reported outcomes?. J Am Acad Orthop Surg 2017; 25 (Suppl. 01) S55-S59
• 32 Value Based Programs 2017. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html . Accessed July 17, 2018
• 33 Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Med Care 2016; 54 (02) 140-146
• 34 SOCIETY OF ACTUARIES. Indications of Pent-up Demand New ACA enrollee use of preference-sensitive services. n.d. Available at: https://www.soa.org/Files/Research/Projects/2015-pent-up-demand.pdf . Accessed August 16, 2018
• 35 The evolving Affordable Care Act marketplaces: The 2015 to 2016 transition | Blue Cross Blue Shield n.d. Available at: https://www.bcbs.com/the-health-of-america/reports/evolving-affordable-care-act-marketplaces-2015-2016-transition . Accessed July 20, 2018
• 36 Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee G-C. Should All Patients Be Included in Alternative Payment Models for Primary Total Hip Arthroplasty and Total Knee Arthroplasty?. J Arthroplasty 2016; 31 (09) 45-49
• 37 Courtney PM, Huddleston JI, Iorio R, Markel DC. Socioeconomic risk adjustment models for reimbursement are necessary in primary total joint arthroplasty. J Arthroplasty 2017; 32 (01) 1-5
• 38 Centers for Medicare & Medicaid Services. BPCI Advanced Target Price Specifications Model Years 1 and 2. 2018 Available at: https://innovation.cms.gov/files/x/bpciadvanced-targetprice-my1-2.pdf . Accessed August 16, 2018
• 39 Hospital Merger and Acquisition Activity Continues Upward Momentum, According to Kaufman Hall Analysis n.d. Available at: http://www.prweb.com/releases/2017/01/prweb13978577.htm . Accessed July 20, 2018
• 40 Martin AB, Hartman M, Washington B, Catlin A. ; National Health Expenditure Accounts Team. National health spending: faster growth in 2015 as coverage expands and utilization increases. Health Aff (Millwood) 2017; 36 (01) 166-176
• 41 Keehan SP, Stone DA, Poisal JA. , et al. National health expenditure projections, 2016-25: price increases, aging push sector to 20 percent of economy. Health Aff (Millwood) 2017; 36 (03) 553-563
• 42 Kim YT, Kang MW, Lee JK, Lee YM, Kim JI. Combined use of topical intraarticular tranexamic acid and rivaroxaban in total knee arthroplasty safely reduces blood loss, transfusion rates, and wound complications without increasing the risk of thrombosis. BMC Musculoskelet Disord 2018; 19 (01) 227
• 43 Xie J, Hu Q, Huang Z, Zhou Z, Pei F. Comparison of three routes of administration of tranexamic acid in primary unilateral total knee arthroplasty: analysis of a national database. Thromb Res 2019; 173: 96-101
• 44 Huerfano E, Huerfano M, Shanaghan KA, Gonzalez Della Valle A. Topical tranexamic acid in revision total knee arthroplasty reduces transfusion rates and may be associated with earlier recovery. J Arthroplasty 2019; 34 (7S): S249-S255
• 45 Gaffney CJ, Pelt CE, Gililland JM, Peters CL. Perioperative pain management in hip and knee arthroplasty. Orthop Clin North Am 2017; 48 (04) 407-419
• 46 Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 years. N Engl J Med 2015; 372 (25) 2451-2458
• 47 HAC-Reduction-Program 2017. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html . Accessed July 22, 2018