Posted June 30, 2017 – Amy S. Wasterlain, MD; Ricardo J. Bello, MD, MPH; Jonathan Vigdorchik, MD; Ran Schwarzkopf, MD, MSc; William J. Long, MD, FRCSC
Abstract
Declining total joint arthroplasty reimbursement and rising implant prices have led many hospitals to restrict access to newer, more expensive total joint arthroplasty implants. The authors sought to understand arthroplasty surgeons’ perspectives on implants regarding innovation, product launch, costs, and cost-containment strategies including surgeon gain-sharing and patient cost-sharing. Members of the International Congress for Joint Reconstruction were surveyed regarding attitudes about implant technology and costs. Descriptive and univariate analyses were performed. A total of 126 surgeons responded from all 5 regions of the United States. Although 76.9% believed new products advance technology in orthopedics, most (66.7%) supported informing patients that new implants lack long-term clinical data and restricting new implants to a small number of investigators prior to widespread market launch. The survey revealed that 66.7% would forgo gain-sharing incentives in exchange for more freedom to choose implants. Further, 76.9% believed that patients should be allowed to pay incremental costs for “premium” implants. Surgeons who believed that premium products advance orthopedic technology were more willing to forgo gain-sharing (P=.040). Surgeons with higher surgical volume (P=.007), those who believed implant companies should be allowed to charge more for new technology (P<.001), and those who supported discussing costs with patients (P=.004) were more supportive of patient cost-sharing. Most arthroplasty surgeons believe technological innovation advances the field but support discussing the “unproven” nature of new implants with patients. Many surgeons support alternative payment models permitting surgeons and patients to retain implant selection autonomy. Most respondents prioritized patient beneficence and surgeon autonomy above personal financial gain. [Orthopedics. 201x; xx(x):xx–xx.]
During the past 20 years, increasing costs for total hip arthroplasty and total knee arthroplasty have outpaced increases in reimbursement.1 Implant costs can comprise up to 50% of Medicare’s reimbursement for the entire procedure and hospitalization.2,3 This rise in costs without a commensurate rise in reimbursement threatens hospitals’ financial stability and may therefore reduce patient access to care. In response, numerous cost-containment strategies have been proposed and implemented to reign in these costs. Value-based alternative payment models such as the Medicare bundled payment provide a fixed fee for all costs associated with a total joint arthroplasty, incentivizing all players to collaborate to provide better quality care at lower cost.4 Many hospitals have subsequently developed guidelines for implant use, restricting access to more expensive or newer implants.
Gain-sharing attempts to realign hospital and physician incentives by compensating surgeons for making cost effective decisions that yield savings for the hospital.4 Compensation may be in the form of bonus payments, additional personnel resources such as physician assistants, research funds, or another item of value to the physician or the department.5 Although surgeons may reap small rewards from gain-sharing, they may have less autonomy to choose the implants they believe are best for their patients.
