Knee replacements are up 17% and hip replacements by 33% from 2010-2017, according to a review of medical claims data from the Blue Cross Blue Shield Association.
More and more Americans, including younger ones, are choosing to have hip and knee replacements, and as they do, the costs associated with these procedures continue to rise.
A new notice data on medical claims from 2010 to 2017 by the Blue Cross Association Blue Shield (BCBSA) found that knee replacements increased by 17% and hip replacements by 33%.
With a price tag of more than $ 25 billion for commercially insured adult BCBS members in 2017, planned orthopedic surgeries accounted for 47% of total orthopedic spending, reflecting a 44% increase since 2010, according to the journal.
During the same period, the average price of knee and hip procedures increased by 6% and 5% respectively.
Hospitalized or outpatient?
The BCBSA review also analyzed claims data based on whether the procedures were performed in an outpatient or inpatient facility.
He found that outpatient knee and hip procedures cost much less than inpatient.
The average price for an inpatient knee replacement is $ 30,249, compared to $ 19,002 in an outpatient setting. The average cost of an inpatient hip replacement is $ 30,685 compared to $ 22,078 in an outpatient setting.
Additionally, outpatient complication rates improved between 2013 and 2017 by 23% for knee procedures and 36% for hip procedures, making them comparable to a hospital setting, according to the review.
Despite the potential savings, the BCBSA review showed that only 11% of knee procedures and 8% of hip procedures were performed on an outpatient basis in 2017.
That could change, however, due to confusion and lack of guidance on Medicare’s knee replacement rules, which saw total knee replacement surgery removed from the list of inpatient only (IPO) procedures. Medicare in the 2018 Medicare Outpatient Prospective Payment System Final Rule.
According to a survey conducted last year by the American Association of Hip and Knee Surgeons, the new rule has caused many hospitals to treat all Medicare beneficiaries undergoing total knee replacement surgery on an outpatient basis.
However, CMS noted in his rule that just because a procedure was removed from the list of SOPs ” not require that the procedure be performed only on an outpatient basis “and that physicians should use their expertise to determine which patients should undergo the procedure on an inpatient or outpatient basis.
There are also large price variations for knee and hip procedures between and even within statistical metropolitan areas, the BCBSA review showed.
For example, in San Antonio, the highest price for a knee replacement is almost three times that of the cheapest procedure, and in Dallas, the highest price for a hip replacement. is almost four times that of the cheapest intervention. .
Between Des Moines, Iowa, and New York, NY, prices for knee and hip procedures vary more than triple.
“To effectively manage health care costs and ensure access to care, consumers, employers and industry leaders need to have information about these price changes and provide the tools to become informed buyers. “Mark Talluto, BCBSA vice president of strategy and analytics, told HealthLeaders via email. .
Efforts to increase transparency are mixed. For example, new CMS rules require every hospital in the United States to publish a standard price list online in a machine-readable format.
However, there is currently no penalty for hospitals that do not comply. And even when hospitals release their leads, patients can struggle to find the document and decipher its medical jargon, acronyms, and atomized list of codes.
Towards a value-based refund
Due to the high volume and cost of these procedures, orthopedic surgery is an area ripe for developing new and better ways for hospitals to be reimbursed.
It is “important to continue to move payment for health care from the traditional fee-for-service model – which rewards the volume of medical services provided – to a model that links reimbursement to the quality of care, improvement of patient outcomes and guides members to the most appropriate care. settings, ”Talluto said.
Work is already underway on this front. For example, Brigham and Women’s Hospital In Boston recently received a grant develop quality measures of orthopedic surgery, most of which relate to total knee and hip arthroplasty, for use in medicare Quality payment program (QPP), which changes the way Medicare pays providers Schedule of physician fees.
The RRQ rewards “high-value, high-quality Medicare clinicians with payment increases, while reducing payments to clinicians who do not meet performance standards,” according to the CMS website.
With over 1 million procedures Every year, hip and knee replacements have long been an area in which hospitals seek to improve their financial performance.
“Organizations that think about their revenue cycle tend to focus particularly on how they can do with the hips and knees,” David Bates, MD, Chief of General Internal Medicine at Brigham and Women’s Hospital and Director of Patient Safety Research and Practice Center, Recount Health leaders Last year.
Alexandra Wilson Pecci is a writer for HealthLeaders.