Disparate financial incentives for hospitals and surgeons to perform total shoulder arthroplasty in higher-risk patients.
Academic Article
Overview
abstract
BACKGROUND: Despite heightened focus on delivering high-value, cost-conscious healthcare, existing reimbursement practices differ for hospital systems and surgeons. This study aimed to investigate the relationship between patient risk and reimbursement for hospitals and surgeons among US Medicare patients undergoing primary total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of clinical and financial data was performed using the publicly available "2022 Medicare Physician and Other Practitioner" and "2022 Medicare Inpatient Hospitals" files. Patients were dichotomized into a sicker cohort, defined as a Hierarchical Condition Category (HCC) risk score of 1.5 or greater, and a healthier cohort with HCC risk scores less than 1.5. Surgeon and hospital reimbursement data were collected and compared across patient cohorts. RESULTS: In 2022, 79,668 TSA procedures were billed to US Medicare, with an overall mean surgeon reimbursement of $798.04. Among these patients, 1065 had an HCC risk score greater than 1.5 and were categorized as high-risk, while the remaining 78,603 patients had lower scores and were categorized as standard-risk. Mean surgeon reimbursement for the high-risk cohort trended to be less than the standard-risk cohort ($787.78 vs. $798.19). Among patients in the high-risk cohort, HCC risk score had a significant negative effect on mean surgeon reimbursement (P < .001). Among 16,734 Medicare patients who were admitted as inpatients for primary shoulder arthroplasty in 2022, the mean hospital reimbursement was $18,586.60. In contrast to surgeon reimbursement, hospital reimbursement was significantly greater for the high-risk cohort, with a mean payment of $19,063.27 compared to $15,239.36 for the standard-risk cohort (P < .001). CONCLUSIONS: Although US hospital reimbursement for TSA increased among higher-risk patients with greater medical comorbidities, surgeon reimbursement among higher-risk patients was relatively unchanged, with a trend toward a small decrease. Such a discrepancy may create disparate incentives for hospitals and surgeons to take on extra risk in caring for complex patients. These data may inform future healthcare policies that promote continued access to shoulder arthroplasty care among higher-risk patients.
