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This acetabular component requires revision because of polyethylene wear. The previous trochanteric osteotomy has healed through fibrous union and could be used to access the hip joint for the revision. However, the shoulder of exposed cement underneath the trochanteric fragment means that problems with further trochanteric union could be expected using this approach. The surgery was performed through a transgluteal approach, and the fibrous union was left undisturbed. Reproduced from Duncan DP, Howell JR, Masri, BA: Revision Total Hip Arthroplasty: Surgical Approaches, in Lieberman JR, Berry DJ, Eds: Advanced Reconstruction Hip. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, P. 293.

AAOS Now

Published 5/1/2014
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Terry Stanton

Is Medicare Reimbursement for Revision TJA Adequate?

Implications for patient access to care could be significant

Under the Medicare physician fee schedule, surgical fees are higher for revision total joint arthroplasty (TJA) than for primary joint arthroplasties, but is the increased reimbursement proportional to the time and effort involved in revision surgery? According to research presented at the 2014 AAOS Annual Meeting, the answer is “no,” and that could be problematic in the future, as numbers of both primary and revision TJAs increase.

Presenter Gregory K. Deirmengian, MD, of the Rothman Institute, noted that the situation could be compounded by a predicted shortfall in the supply of surgeons able to perform arthroplasties and the number of fellowship-trained surgeons able to perform revisions relative to demand.

Based on the research conducted by Dr. Deirmengian, revision TJA surgeries take approximately twice as long as primary surgeries. In addition, revision surgeries have a higher rate of repeat surgery within 90 days—the “global period” covered by the primary surgery’s reimbursement. These factors contribute to a negative incentive for surgeons to perform revision arthroplasties.

Measuring time, effort
To establish the differences in time expended among procedures, the authors used their institutional database to identify all aseptic hip and knee arthroplasty procedures performed by one surgeon over 2 years (2010–2011). The surgeon had extensive experience with revision procedures and, during the timeframe of the study, focused a large proportion of his practice on revision arthroplasty.

For each case, electronic hospital and office medical records were used to collect surgical indications, procedures performed, total surgical time, total length of hospital stay, and repeat procedures within 90 days of the index procedure. Surgeon reimbursements for individual procedures were obtained from publicly available Medicare reimbursement data for the studied years.

Revision procedures were stratified based on a detailed review of all operative notes. All revision procedures involving only the exchange of modular components were classified as “simple” revisions. Knee revision procedures requiring the removal of well-fixed revision components and hip revision procedures requiring the removal of well-fixed revision femoral components and/or acetabular revisions requiring structural augmentation or a cage prosthesis were classified as “complex” revisions. All other revision procedures were classified as “standard” revisions.

Using the data collected, the authors calculated the average surgical time for each type of procedure. Next, they calculated the total surgical time spent by the surgeon on all procedures during the study period to establish the total surgical time spent per year by the surgeon.

“Using Medicare reimbursement rates, we determined the compensation that would be collected by the surgeon with operative time spent on different proportions of the various procedures performed,” Dr. Deirmengian said. Secondary variables used as a measure for time and effort employed by the surgeon for different procedure types included reoperation within 90 days and length of hospital stay.

Among total hip arthroplasty (THA) procedures, revision procedures were associated with a 1.8-fold increase in surgical time compared to primary THA procedures (P < 0.001). When stratified by complexity and compared with primary THA, “complex” revisions were associated with a 2.6-fold increase in surgical time (P < 0.001), “standard” revisions were associated with a 1.7-fold increase in surgical time (P < 0.001), and “simple” revisions were associated with a 1.4-fold increase in surgical time (P < 0.001).

Similarly, revision total knee arthroplasty (TKA) procedures were associated with a 1.8-fold increase in surgical time compared with primary TKA (P < 0.001). When stratified by complexity and compared with primary TKA, complex revisions were associated with a 2.4-fold increase in surgical time (P < 0.001) and “standard” revisions were associated with a 1.8-fold increase in surgical time (P < 0.001).

The need for incentives
Dr. Deirmengian noted that revision procedures also have a higher risk of complications and may require the surgeon to spend more time with patients both before and after surgery. “Our study suggests that Medicare fails to adequately reimburse surgeons for the added time and effort associated with revision arthroplasty,” he said.

The study authors determined that a surgeon who chooses to focus his or her practice exclusively on revision arthroplasty procedures may expect to receive just a third of the total reimbursement that a practice focused exclusively on primary arthroplasty might expect to receive.

They concluded: “The disparity between reimbursement and the time needed to perform revision surgeries raises concerns about patient access to surgeons who would be willing to undertake these surgeries in the future. With an increasing demand for orthopaedic surgeries in conjunction with this predicted decrease in trained surgeons, it is possible that the current Medicare reimbursement structure will limit patients’ access to surgeons willing or able to perform complex revision TJAs.”

Dr. Deirmengian’s coauthors of “Medicare Fails to Compensate Additional Time and Effort Associated with Revision Arthroplasty” are Anthony T. Tokarski, BS; Carl A. Deirmengian, MD; Paul M. Lichstein, MD, MS; and Matthew S. Austin, MD.

Disclosure information: Gregory K. Deirmengian, MD—Angiotech, Zimmer, Synthes, Biomet, CD Diagnostics, Journal of Bone and Joint Surgery (JBJS), Journal of Arthroplasty. Carl A. Deirmengian, MD—Zimmer, Synthes, Biomet, Biostar Venture Fund, CD Diagnostics, Trice, Domain, CD Diagnostic, JBJS. Dr. Austin—Zimmer, Journal of Arthroplasty, American Association of Hip and Knee Surgeons. Mr. Tokarski and Dr. Lichstein—no conflicts.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.

Bottom Line

  • Revision arthroplasty procedures are often more complex, take longer, and have a higher risk of complications than primary arthroplasty procedures.
  • Medicare payments for revision arthroplasty procedures are higher than those for primary arthroplasty procedures; however, these payments may not sufficiently take into account the time or complexity of revision surgeries.
  • This study found that orthopaedic surgeons who focus on performing revision arthroplasty procedures would make approximately one third of the reimbursements paid to orthopaedic surgeons who focus on performing primary arthroplasty procedures.