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Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries
TagedEnThe Journal of Foot & Ankle Surgery 59 (2020) 5−8
Contents lists available at ScienceDirect
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The Journal of Foot & Ankle Surgery TagedEn
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journal homepage: www.jfas.org
TagedH1Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare BeneficiariesTagedEn T zeem Tariq Malik, MBBS1, Carmen E. Quatman, MD, PhD2, Thuan V. Ly, MD3, agedPA Laura S. Phieffer, MD3, Safdar N. Khan, MD3TagedEn 1
TagedP Research Fellow, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 2 Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 3 Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
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TAGEDPA R T I C L E
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TagedEnTagedPLevel of Clinical Evidence: 3 TagedEn TagedEnTagedPKeywords:
ankle fracture bundled payment 90-day costs Medicare ORIF risk adjustment TagedEn
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TagedPAs the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers
of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005−2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post−acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patientlevel (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 § $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.TagedEn © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
TagedPConstituting nearly 18% of the gross domestic product in 2017 (1), healthcare spending in the United States is among the highest in the world. Mirroring the surge in economic growth and longevity, healthcare spending is projected to increase even further (2). Given the unsustainable trajectory of healthcare spending, health policy makers are beginning to focus their efforts on ways to curb costs and reduce the economic burden on the healthcare system. One such initiative involves the introduction and gradual adoption of “bundled payments” as an alternative to the current “fee-for-service” payment model for several high-cost medical
TagedEnFinancial Disclosure: None reported. TagedEnConflict of Interest: None reported. TagedEnAddress correspondence to: Azeem Tariq Malik, MBBS, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Avenue, Columbus, OH 43210. E-mail address: [email protected] (A.T. Malik).
conditions and/or surgical procedures (3). In contrast to the fee-for-service system, where each provider associated with a medical/surgical episode of care is reimbursed separately based on the type/level of care they provide, bundled payments aim to align the incentives of all providers by means of risk-sharing of payments, enhanced coordination of care, and promotion of cost-containment strategies in an attempt to bring down the overall cost without compromising the delivery of quality care (4−6). Most of the current bundled-payment programs in orthopaedics have focused their efforts on elective total joint arthroplasties (7), with preliminary studies showing a significant reduction in overall costs of care (8,9). Given the promising results of bundled payments in such elective total joint arthroplasties, health policy makers have sought to extend such alternative payment models to orthopaedic trauma fractures (10). However, the implementation of bundled payments in the latter has been a matter of major scrutiny due to the potential for high variability in costs (11).TagedEn
1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.05.004
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A.T. Malik et al. / The Journal of Foot & Ankle Surgery 59 (2020) 5−8
TagedPAlthough recent research has identified cost drivers of a 90-day episode of care after geriatric hip fractures (11), the literature on investigations of the same for isolated ankle fractures in the elderly is largely limited (12). Because the overall incidence of ankle fracture is expected to triple by 2030 (13), it is not unreasonable to surmise that this fracture will be responsible for a significant cost burden on the healthcare system in the near future. Bundled payments may offer healthcare systems a way of out of the impending economic burden of this fracture type. Unfortunately, a lot of ground remains to be covered, such as identifying cost drivers that will help health policy makers in risk-adjusting prospective target prices of bundled payments in ankle fractures to ensure equitable care. In the light of the latter observations, we used a national Medicare claims data set and conducted a comprehensive analysis to identify patient-level, procedure-level, and state-level factors associated with significant cost variation in a 90-day episode of care after open reduction and internal fixation (ORIF) of isolated ankle fractures.TagedEn TagedH1Patients and MethodsTagedEn TagedH2Database and Patient SelectionTagedEn TagedPWe conducted a cost-analysis study by using the 5% Medicare Standard Analytical Files data set for 2005−2014. The PearlDiver research software (Colorado Springs, CO; http://pearldiverinc.com/), a comprehensive fast-processing research repository, was used to query the 5% Medicare Standard Analytical Files data set through the use of Current Procedural Terminology codes to identify patients undergoing ORIF for unimalleolar (27766, 27769, 27792), bimalleolar (27814), and trimalleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee, or tibia were removed from the study to capture a relevant cohort of patients with isolated ankle fractures. A complete list of exclusion codes is given in Appendix 1. All payments made for acute care (surgeons, anesthesiologists, and facility) and post−acute care (office visits, radiology, physical therapy/rehabilitation/ skilled nursing facility. and readmissions) starting from day 0 of surgery to day 90 postoperatively were used to calculated 90-day costs. Patients with missing data with regard to age, sex, and state were excluded. Any patient who died during the 90-day follow-up period and/or had missing data was also excluded to prevent erroneous calculation of 90-day costs. Because the PearlDiver software retrieves and presents data in a deidentified aggregate format, the study was exempt from institution review board approval.TagedEn TagedPPatient-level factors that were analyzed as part of the study included age, sex, and comorbidities. Procedure-level factors included location of surgery (inpatient vs outpatient facility), fracture morphology (unimalleolar vs bimalleolar vs trimalleolar), type of fracture (open vs closed), use of ankle arthroscopy, and presence of concurrent syndesmotic injury requiring fixation. A complete list of International Classification of Diseases, Ninth Edition codes, Service Location codes, and Current Procedural Terminology codes used to retrieve the previously mentioned factors/categories can be found in Appendix 1.TagedEn
TagedEnTable 1
Average 90-day reimbursement for all ankle fractures
All ankle fractures
Number of patients
90-Day average reimbursement
6499
$15,023 § $15,091
TagedEnTable 2
Reimbursement adjustment based on sex and age groups
Sex Female Male Age, yr <65 65 to 69 70 to 74 75 to 79 80 to 84 ≥85
Number of patients (%)
Reimbursement adjustment (+/−)
4903 (75.4%) 1596 (24.6%)
Ref. +$756 § $423
1355 (20.8%) 1393 (21.4%) 1276 (19.6%) 961 (14.8%) 802 (12.3%) 713 (11.0%)
+$1967 § $552 Ref. +$1761 § $549 +$1869 § $595 +$1994 § $644 +$2568 § $679
P value
.076 <.001* .001* .002* .002* <.001*
NOTE. P values represent comparison with reference groups as indicated. * Significance at P < .05.
(+$1994; P = .002), <65 years (+$1967; P < .001), 75 to 79 years (+$1869; P = .002), and 70 to 74 years (+$1761; P = .001) (Table 2). Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577; P < .001), trimalleolar fracture (+$1082; P = .030), and syndesmotic fixation (+$2822; P < .001) (Table 3).TagedEn TagedPThe following comorbidities were found to be significant cost drivers during the 90-day episode of care: chronic kidney disease (+$8897; P < .001), malnutrition (+$7908; P = .004), obesity (+$5362; P < .001), cerebrovascular disease/stroke (+$4159; P < .001), anemia (+$3087; P < .001), congestive heart failure (+$2395; P < .001), chronic obstructive pulmonary disease (+$1932; P < .001), diabetes mellitus (+$1243), and ischemic heart disease (+$1261) (Table 4).TagedEn TagedPSignificant state-level variation in 90-day costs was seen, with Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), Maryland (+$3043), and Texas (+$2556; P = .019) having the highest marginal cost increase compared with Michigan, whereas Idaho (−$6025; P = .010) and Wisconsin (−$3061; P = .035) had the lowest marginal cost impacts (Table 5).TagedEn
TagedH2Statistical AnalysisTagedEn TagedPGeneralized multivariate linear regression modeling was used to calculate the independent marginal cost impact (increase/decrease) of individual patient-level, procedurelevel, and state-level factors on 90-day costs while controlling for other covariates. The final regression model included the following variables: age, sex, location of surgery, fracture morphology, type of fracture, use of ankle arthroscopy, concurrent syndesmotic fixation, comorbidities, and state. Results from multivariate regression analyses have been reported as adjusted marginal cost impacts (+/ ) in US dollars, along with standard errors and respective P values. For state-level analyses, comparison was made by using Michigan as a reference. For all statistical purposes, a value of P < .05 was considered significant. All analyses were performed by using the PearlDiver research software, which uses R statistics at the back end to conduct and provide statistical analyses/outputs to users.TagedEn
TagedH1ResultsTagedEn TagedPAfter the application of inclusion/exclusion criteria, a total of 6499 patients were included in the study. The 90-day average reimbursement for the 6499 ankle fractures undergoing ORIF was $15,023 § $15,091 (Table 1). The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 § $1060. Individuals aged <65 or ≥70 years had significantly higher costs (Table 2). The highest marginal cost impacts for age, in decreasing order of effect, were for individuals aged ≥85 years (+$2568; P < .001), 80 to 84 years
TagedH1DiscussionTagedEn TagedPAlthough bundled payments are gaining popularity across the healthcare landscape, a lot of controversy still shrouds these
TagedEnTable 3
Marginal impact of procedural-level factors on 90-day reimbursements after controlling for age, sex, comorbidities, and state
Location of surgery Inpatient Outpatient Fracture morphology Unimalleolar Bimalleolar Trimalleolar Type of fracture Open Closed Use of ankle arthroscopy Syndesmotic injury/fixation * Significance at P < .05.
Number of patients (%)
Reimbursement adjustment (+/−)
4724 (72.7%) 1775 (27.3%)
+$5577 § $410 Ref.
1417 (21.8%) 3130 (48.2%) 1952 (30.0%)
Ref. +$437 § $464 +$1082 § $498
984 (15.1%) 5515 (84.9%) <11 (<0.2%) 611 (9.4%)
+$911 § $497 Ref +$2683 § $4470 +$2822 § $607
P value <.001*
.346 .030* .067 .548 <.001*
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TagedEnTable 4
TagedEnTable 5
Marginal impact of costs by individual comorbidities
Comorbidity Congestive heart failure Ischemic heart disease Hyperlipidemia Hypertension Parkinson disease Alzheimer disease Cerebrovascular/stroke Chronic obstructive pulmonary disease Diabetes mellitus Hypothyroidism Chronic kidney disease Chronic liver disease Malignancy Inflammatory disorder Coagulopathy Hypercoagulopathy Osteoporosis Obesity Anemia Alcohol use Tobacco use Drug abuse Depression/bipolar Anxiety disorder Malnutrition
7
Marginal impact of state-level variation on costs with the state of michigan taken as the reference
Number of patients (%)
Reimbursement adjustment (+/−)
P value
585 (9.0%) 1042 (16.0%) 1559 (24.0%) 3155 (48.5%) 58 (1.2%) 122 (1.9%) 403 (6.2%) 894 (13.8%)
+$2395 § $671 +$1261 § $530 −$2265 § $459 −$1743 § $408 −$1462 § $1875 +$1511 § $1321 +$4159 § $752 +$1932 § $536
<.001* .017* <.001* <.001* .436 .253 <.001* <.001*
1564 (24.1%) 695 (10.7%) 576 (8.9%) 97 (1.5%) 251 (3.9%) 153 (2.4%) 148 (2.3%) <11 (<0.2%) 803 (12.4%) 93 (1.4%) 755 (11.6%) 38 (0.6%) 247 (3.8%) 49 (0.8%) 653 (10.0%) 356 (5.5%) 27 (0.4%)
+$1243 § $457 −$1271 § $590 +$8897 § $667 +$1576 § $1475 +$1108 § $920 +$652 § $1171 +$4049 § $1198 −$1298 § $5014 −$591 § $552 +$5362 § $1498 +$3087 § $597 −$485§ $2342 −$235 § $952 −$688 § $2066 +$89 § $651 +$947 § $834 +$7908 § $2748
.007* .031* <.001* .285 .228 .578 <.001* .796 .284 <.001* <.001* .836 .805 .739 .256 .256 .004*
* Significance at P < .05.
alternative payment models. The concept of shifting the “risk” onto providers is one not keenly looked upon in orthopaedic trauma, given that most physicians strongly feel that the “one-size-fits-all” approach of bundled payments is not feasible when performing complex fracture fixations or taking care of sicker patients. By conducting a comprehensive cost analysis using a nationally representative database, our results reflect these concerns by rightfully identifying several patientlevel, procedure-level, and state-level factors that were responsible for producing significant variation in 90-day costs after surgical fixation of isolated ankle fractures.TagedEn TagedPThe significantly lower costs seen in patients aged 65 to 69 years compared to individuals <65 years old can be explained by Medicare eligibility. All individuals >65 years old are automatically eligible for Medicare coverage, but certain patients (such as those with disability, amyotrophic lateral sclerosis, and/or chronic kidney disease) who are <65 years old may also be eligible for Medicare. Given that these patients <65 years old are much more functionally dependent and/or sicker, it is not surprising they have significant higher risk-adjusted 90day costs compared with individuals aged 65 to 69 years.TagedEn TagedPPrior literature has shown outpatient ankle fracture surgery to not only reduce overall facility costs but also yield a protective effect in terms of lower rates of complications (14,15). With regard to the economics of outpatient facilities, Varacallo et al (12) analyzed 299 patients undergoing ORIF for isolated ankle fractures in ambulatory/outpatient centers and noted a similar cost reduction of around $6000 compared with inpatient surgery. Similarly, Bettin et al (16) analyzed 148 ankle fractures undergoing ORIF from a single institution and noted a 32% reduction in 90-day costs for individuals who received surgery in an outpatient setting. However, although there is an increasing push toward performing surgery in an outpatient setting, to reduce costs (17), providers should not overlook the need of inpatient care for individuals who ultimately would benefit from it.TagedEn TagedPOur findings also shine light on the need of risk-adjusting payments based on procedure heterogeneity and fracture morphology. Without a comprehensive risk adjustment based on fracture patterns and/or
State and District of Columbia
Number of patients (%)
Reimbursement adjustment (+/−)
Alabama Arkansas Kansas Oklahoma Louisiana Florida Tennessee Utah Iowa Missouri Mississippi Georgia North Dakota Montana Ohio South Carolina South Dakota Idaho Texas Nebraska Kentucky Virginia Nevada Pennsylvania Indiana Wisconsin North Carolina Maine New Mexico Minnesota Illinois Delaware West Virginia Colorado Arizona New Jersey Rhode Island Washington New Haven Connecticut Hawaii New York Vermont District of Columbia Massachusetts California Alaska Maryland Puerto Rico Michigan
162 (2.5%) 73 (1.1%) 85 (1.3%) 84 (1.3%) 87 (1.3%) 375 (5.8%) 203 (3.1%) 43 (0.7%) 84 (1.3%) 204 (3.1%) 96 (1.5%) 188 (2.9%) 17 (0.3%) 35 (0.5%) 249 (3.8%) 114 (1.8%) 26 (0.4%) 43 (0.7%) 501 (7.7%) 61 (0.9%) 117 (1.8%) 172 (2.6%) 32 (0.5%) 301 (4.6%) 189 (2.9%) 150 (2.3%) 261 (4.0%) 48 (0.7%) 31 (0.5%) 120 (1.8%) 301 (4.6%) 13 (0.2%) 51 (7.8%) 87 (1.3%) 111 (1.7%) 157 (2.4%) 20 (0.3%) 140 (2.2%) 30 (0.5%) 69 (1.1%) <11 (<0.2%) 284 (4.4%) 16 (0.2%) 14 (0.2%) 135 (2.1%) 403 (6.2%) <11 (<0.2%) 141 (2.2%) <11 (<0.2%) 254 (3.9%)
−$2001 § $1415 +$437 § $1869 −$274 § $1765 +$4002 § $1774 −$49 § $1751 $2057 § $1146 −$1384 § $1326 −$1992 § $2323 −$2308 § $1774 −$953 § $1323 −$4671 § $2538 −$1891 § $1356 −$1847 § $3537 −$4671 § $2538 −$1075 § $1258 +$326 § $1589 −$1567 § $2903 −$6025 § $2327 +$2556 § $1086 −$1281 § $2008 −$136 § $1574 −$1549 § $1391 +$6371 § $2645 −$640 § $1202 −$2196 § $1354 −$3061 § $1452 −$1120 § $1242 −$1829 § $2222 +$986 § $2679 −$2231 § $1561 +$212 § $1201 +$3801 § $4002 −$2683 § $2163 −$907 § $1751 +$2256 § $1604 +$3802 § $1433 +$130 § $3272 −$105 § $1484 +$329 § $2720 −$474 § $1919 +$2136 § $4777 +$1988 § $1218 −$300 § $3630 $84 § $3867 +$4497 § $1504 +$955 § $1130 +$5317 § $4780 +$3043 § $1480 −$9022 § $5397 Ref.
P value .157 .815 .876 .024* .976 .073 .297 .391 .193 .471 .066 .163 .601 .066 .393 .838 .589 .010* .019* .523 .931 .265 .016* .594 .105 .035* .367 .410 .713 .153 .860 .342 .215 .604 .160 .008* .968 .943 .904 .805 .654 .103 .934 .982 .003* .398 .266 .040* .095
* Significance at P < .05.
concurrent syndesmotic injury, providers may actually be disincentivized toward taking care of patients with complex cases. For instance, prior research has shown complex fracture patterns to be associated with higher risk of complications (18), readmissions (19), and subsequent costs (20). A bundle that does not account for fracture complexity will only end up causing major financial losses to healthcare systems (such as Level 1 trauma centers) that regularly receive complex fracture referrals from adjoining areas. Similarly, a lack of additional payment for treating concurrent syndesmotic injury in ankle fractures may also prevent providers from providing quality care to their patients.TagedEn TagedPThe cost impact of comorbidities often remains an overlooked corner in the era of value-based care. This is primarily because most health policy makers strongly believe that providers should try their best to preoperatively optimize individuals with modifiable comorbidities
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before surgery. However, although cost-containment strategies such as preoperative optimization of medically complex patients (e.g., weight loss in obese patients and/or reduction of glycated hemoglobin levels in individuals with diabetes) may be feasible in an elective total joint arthroplasty patient population, such options are not entirely available for physicians dealing with an urgent fracture. Such medically complex fracture patients may be considered “bundle busters” for whom the high costs of care would continually exceed the target price, resulting in unfair financial losses for the healthcare system. Given that different comorbidities have varying marginal cost impacts (e.g., +$1200 for diabetes mellitus vs +$7900 for malnutrition), our findings also highlight the importance of ensuring prospective payments are risk adjusted on the presence/absence of individual comorbidities. We believe that this form of risk adjustment is more robust in contrast to the Centers for Medicare and Medicaid Services use of broad comorbidity risk-assessment groups, such as “CC/MCC” modifiers, which do not completely account for all comorbidities (21), to risk adjust bundled payments in the comprehensive joint replacement model.TagedEn TagedPFinally, as bundled payments begin to be implemented nationally, health policy makers also need to take into account the significant state-level variation seen in 90-day costs. Briefly summarizing, in line with prior literature, a majority of the high-cost states appear to be concentrated in the Northeast (Massachusetts, Maryland, New Jersey), with the remaining high-cost areas being rather sporadic in distribution − Oklahoma and Texas in the South and Nevada in the West. Although the higher costs in the Northeastern states can be largely explained by general greater healthcare expenditures in that region, the higher costs in certain states such as Nevada and Oklahoma can be due to lower hospital market concentration (22) driving up payments.TagedEn TagedPThere are several limitations to the study. First, although we used a nationally representative data set of Medicare beneficiaries, these administrative data sets are prone to miscoding and billing errors. Second, the smaller sample sizes seen in certain variables (e.g., ankle arthroscopy and specific states such as Alaska and Hawaii) may be introducing a type II error in our study. We did not evaluate the marginal cost impacts of readmissions and post−acute care stays, because these are likely factors that Medicare will not use to risk-adjust prospective payments beforehand. In addition, because we were already analyzing the impact of individual comorbidities on 90-day costs, further including readmissions and post−acute care use would introduce multicollinearity in the study. Finally, in anticipation of expansion of current Centers for Medicare & Medicaid bundled-payment models, we only looked at elderly Medicare patients and not a younger cohort of patients who also experience ankle fractures and may have a different postoperative course of care and resource utilization. We also did not account for inflation over the time period, because that was beyond the scope of the study. It is likely that the calculated costs are underestimates of the actual costs in the current time period.TagedEn TagedPIn conclusion, with the use of a national administrative database of Medicare beneficiaries, the study highlights several important patientlevel, procedure-level, and state-level factors responsible for producing significant variation in 90-day costs. As the orthopaedic trauma world gradually evolves toward the adoption of bundled-payment models as a mainstay for reducing cost burden associated with lower extremity fractures, our findings facilitate discussion on the need of prior risk adjustment of prospective payment models to ensure that providers catering to complex ankle fractures and/or sicker patient populations are adequately reimbursed to prevent the creation of
financial disincentives and barriers of access to care in the US healthcare system.TagedEn TagedH1Supplementary MaterialsTagedEn TagedPSupplementary material associated with this article can be found in the online version at https://doi.org/10.1053/j.jfas.2019.05.004.TagedEn
TagedH1ReferencesTagedEn TagedP 1. Centers for Medicare & Medicaid Services. National Health Expenditure Data. 2018 Available at: https://www.cms.gov/research-statistics-data-and-systems/statisticstrends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html. Accessed April 20, 2019.TagedEn TagedP 2. Morgan L. US healthcare annual spending estimated to rise by 5.8% on average through 2024. Am Health Drug Benefits 2015;8:272.TagedEn TagedP 3. Chen C, Ackerly DC. Beyond ACOs and bundled payments: Medicare's shift toward accountability in fee-for-service. JAMA 2014;311:673–674.TagedEn TagedP 4. Dietz N, Sharma M, Alhourani A, Ugiliweneza B, Wang D, Nuno MA, Drazin D, Boakye M. Bundled payment models in spine surgery: current challenges and opportunities, a systematic review. World Neurosurg 2019;123:177–183.TagedEn TagedP 5. Piccinin MA, Sayeed Z, Kozlowski R, Bobba V, Knesek D, Frush T. Bundle payment for musculoskeletal care: current evidence (part 2). Orthop Clin North Am 2018;49: 147–156.TagedEn TagedP 6. Piccinin MA, Sayeed Z, Kozlowski R, Bobba V, Knesek D, Frush T. Bundle payment for musculoskeletal care: current evidence (part 1). Orthop Clin North Am 2018;49: 135–146.TagedEn TagedP 7. McLawhorn AS, Buller LT. Bundled payments in total joint replacement: keeping our care affordable and high in quality. Curr Rev Musculoskelet Med 2017;10:370–377.TagedEn TagedP 8. Siddiqi A, White PB, Mistry JB, Gwam CU, Nace J, Mont MA, Delanois RE. Effect of bundled payments and health care reform as alternative payment models in total joint arthroplasty: a clinical review. J Arthroplasty 2017;32:2590–2597.TagedEn TagedP 9. Barnett ML, Wilcock A, McWilliams JM, Epstein AM, Joynt Maddox KE, Orav EJ, Grabowski DC, Mehrotra A. Two-year evaluation of mandatory bundled payments for joint replacement. N Engl J Med 2019;380:252–262.TagedEn Tag edP10. Phieffer L, Page AE, Lundy DW. Are you ready for SHFFT? 2017 Available at: https:// www5.aaos.org/aaosnow/2017/jan/managing/managing02/ Accessed July 10, 2019.TagedEn TagedP11. Cairns MA, Ostrum RF, Clement RC. Refining risk adjustment for the proposed CMS surgical hip and femur fracture treatment bundled payment program. J Bone Joint Surg Am 2018;100:269–277.TagedEn TagedP12. Varacallo MA, Mattern P, Acosta J, Toossi N, Denehy KM, Harding SP. Cost determinants in the 90-day management of isolated ankle fractures at a large urban academic hospital. J Orthop Trauma 2018;32:338–343.TagedEn TagedP13. Murray AM, McDonald SE, Archbold P, Crealey GE. Cost description of inpatient treatment for ankle fracture. Injury 2011;42:1226–1229.TagedEn TagedP14. Shen MS, Dodd AC, Lakomkin N, Mousavi I, Bulka C, Jahangir AA, Sethi MK. Open treatment of ankle fracture as inpatient increases risk of complication. J Orthop Traumatol 2017;18:431–438.TagedEn TagedP15. Qin C, Dekker RG, Blough JT, Kadakia AR. Safety and outcomes of inpatient compared with outpatient surgical procedures for ankle fractures. J Bone Joint Surg Am 2016; 98:1699–1705.TagedEn TagedP16. Bettin C, Nelson R, Rothberg D, Barg A, Lyman M, Saltzman C. Cost comparison of surgically treated ankle fractures managed in an inpatient versus outpatient setting. J Am Acad Orthop Surg 2019;27:e127–e134.TagedEn TagedP17. Qin C, Dekker RG 2nd, Helfrich MM, Kadakia AR. Outpatient management of ankle fractures. Orthop Clin North Am 2018;49:103–108.TagedEn TagedP18. Basques BA, Miller CP, Golinvaux NS, Bohl DD, Grauer JN. Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics. Clin Orthop Relat Res 2015;473:1133–1139.TagedEn TagedP19. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am 2009;91:1042–1049.TagedEn TagedP20. Belmont PJ Jr, Davey S, Rensing N, Bader JO, Waterman BR, Orr JD. Patient-based and surgical risk factors for 30-day postoperative complications and mortality after ankle fracture fixation. J Orthop Trauma 2015;29:e476–e482.TagedEn TagedP21. Ryan SP, Plate JF, Goltz DE, Attarian DE, Wellman SS, Seyler TM, Jiranek WA. Should medical severity-diagnosis related group classification be utilized for reimbursement? An analysis of Elixhauser comorbidities and cost of care. J Arthroplasty 2019;34:1312–1316.TagedEn TagedP22. Cutler DM, Scott Morton F. Hospitals, market share, and consolidation hospitals, market share, and consolidation. JAMA 2013;310:1964–1970.TagedEn
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TagedH1Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare BeneficiariesTagedEn T zeem Tariq Malik, MBBS1, Carmen E. Quatman, MD, PhD2, Thuan V. Ly, MD3, agedPA Laura S. Phieffer, MD3, Safdar N. Khan, MD3TagedEn 1
TagedP Research Fellow, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 2 Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 3 Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
TagedEn
TAGEDPA R T I C L E
I N F O TAGEDN
TagedEnTagedPLevel of Clinical Evidence: 3 TagedEn TagedEnTagedPKeywords:
ankle fracture bundled payment 90-day costs Medicare ORIF risk adjustment TagedEn
TAGEDPA B S T R A C T TAGEDN
TagedPAs the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers
of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005−2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post−acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patientlevel (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 § $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.TagedEn © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
TagedPConstituting nearly 18% of the gross domestic product in 2017 (1), healthcare spending in the United States is among the highest in the world. Mirroring the surge in economic growth and longevity, healthcare spending is projected to increase even further (2). Given the unsustainable trajectory of healthcare spending, health policy makers are beginning to focus their efforts on ways to curb costs and reduce the economic burden on the healthcare system. One such initiative involves the introduction and gradual adoption of “bundled payments” as an alternative to the current “fee-for-service” payment model for several high-cost medical
TagedEnFinancial Disclosure: None reported. TagedEnConflict of Interest: None reported. TagedEnAddress correspondence to: Azeem Tariq Malik, MBBS, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Avenue, Columbus, OH 43210. E-mail address: [email protected] (A.T. Malik).
conditions and/or surgical procedures (3). In contrast to the fee-for-service system, where each provider associated with a medical/surgical episode of care is reimbursed separately based on the type/level of care they provide, bundled payments aim to align the incentives of all providers by means of risk-sharing of payments, enhanced coordination of care, and promotion of cost-containment strategies in an attempt to bring down the overall cost without compromising the delivery of quality care (4−6). Most of the current bundled-payment programs in orthopaedics have focused their efforts on elective total joint arthroplasties (7), with preliminary studies showing a significant reduction in overall costs of care (8,9). Given the promising results of bundled payments in such elective total joint arthroplasties, health policy makers have sought to extend such alternative payment models to orthopaedic trauma fractures (10). However, the implementation of bundled payments in the latter has been a matter of major scrutiny due to the potential for high variability in costs (11).TagedEn
1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.05.004
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TagedPAlthough recent research has identified cost drivers of a 90-day episode of care after geriatric hip fractures (11), the literature on investigations of the same for isolated ankle fractures in the elderly is largely limited (12). Because the overall incidence of ankle fracture is expected to triple by 2030 (13), it is not unreasonable to surmise that this fracture will be responsible for a significant cost burden on the healthcare system in the near future. Bundled payments may offer healthcare systems a way of out of the impending economic burden of this fracture type. Unfortunately, a lot of ground remains to be covered, such as identifying cost drivers that will help health policy makers in risk-adjusting prospective target prices of bundled payments in ankle fractures to ensure equitable care. In the light of the latter observations, we used a national Medicare claims data set and conducted a comprehensive analysis to identify patient-level, procedure-level, and state-level factors associated with significant cost variation in a 90-day episode of care after open reduction and internal fixation (ORIF) of isolated ankle fractures.TagedEn TagedH1Patients and MethodsTagedEn TagedH2Database and Patient SelectionTagedEn TagedPWe conducted a cost-analysis study by using the 5% Medicare Standard Analytical Files data set for 2005−2014. The PearlDiver research software (Colorado Springs, CO; http://pearldiverinc.com/), a comprehensive fast-processing research repository, was used to query the 5% Medicare Standard Analytical Files data set through the use of Current Procedural Terminology codes to identify patients undergoing ORIF for unimalleolar (27766, 27769, 27792), bimalleolar (27814), and trimalleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee, or tibia were removed from the study to capture a relevant cohort of patients with isolated ankle fractures. A complete list of exclusion codes is given in Appendix 1. All payments made for acute care (surgeons, anesthesiologists, and facility) and post−acute care (office visits, radiology, physical therapy/rehabilitation/ skilled nursing facility. and readmissions) starting from day 0 of surgery to day 90 postoperatively were used to calculated 90-day costs. Patients with missing data with regard to age, sex, and state were excluded. Any patient who died during the 90-day follow-up period and/or had missing data was also excluded to prevent erroneous calculation of 90-day costs. Because the PearlDiver software retrieves and presents data in a deidentified aggregate format, the study was exempt from institution review board approval.TagedEn TagedPPatient-level factors that were analyzed as part of the study included age, sex, and comorbidities. Procedure-level factors included location of surgery (inpatient vs outpatient facility), fracture morphology (unimalleolar vs bimalleolar vs trimalleolar), type of fracture (open vs closed), use of ankle arthroscopy, and presence of concurrent syndesmotic injury requiring fixation. A complete list of International Classification of Diseases, Ninth Edition codes, Service Location codes, and Current Procedural Terminology codes used to retrieve the previously mentioned factors/categories can be found in Appendix 1.TagedEn
TagedEnTable 1
Average 90-day reimbursement for all ankle fractures
All ankle fractures
Number of patients
90-Day average reimbursement
6499
$15,023 § $15,091
TagedEnTable 2
Reimbursement adjustment based on sex and age groups
Sex Female Male Age, yr <65 65 to 69 70 to 74 75 to 79 80 to 84 ≥85
Number of patients (%)
Reimbursement adjustment (+/−)
4903 (75.4%) 1596 (24.6%)
Ref. +$756 § $423
1355 (20.8%) 1393 (21.4%) 1276 (19.6%) 961 (14.8%) 802 (12.3%) 713 (11.0%)
+$1967 § $552 Ref. +$1761 § $549 +$1869 § $595 +$1994 § $644 +$2568 § $679
P value
.076 <.001* .001* .002* .002* <.001*
NOTE. P values represent comparison with reference groups as indicated. * Significance at P < .05.
(+$1994; P = .002), <65 years (+$1967; P < .001), 75 to 79 years (+$1869; P = .002), and 70 to 74 years (+$1761; P = .001) (Table 2). Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577; P < .001), trimalleolar fracture (+$1082; P = .030), and syndesmotic fixation (+$2822; P < .001) (Table 3).TagedEn TagedPThe following comorbidities were found to be significant cost drivers during the 90-day episode of care: chronic kidney disease (+$8897; P < .001), malnutrition (+$7908; P = .004), obesity (+$5362; P < .001), cerebrovascular disease/stroke (+$4159; P < .001), anemia (+$3087; P < .001), congestive heart failure (+$2395; P < .001), chronic obstructive pulmonary disease (+$1932; P < .001), diabetes mellitus (+$1243), and ischemic heart disease (+$1261) (Table 4).TagedEn TagedPSignificant state-level variation in 90-day costs was seen, with Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), Maryland (+$3043), and Texas (+$2556; P = .019) having the highest marginal cost increase compared with Michigan, whereas Idaho (−$6025; P = .010) and Wisconsin (−$3061; P = .035) had the lowest marginal cost impacts (Table 5).TagedEn
TagedH2Statistical AnalysisTagedEn TagedPGeneralized multivariate linear regression modeling was used to calculate the independent marginal cost impact (increase/decrease) of individual patient-level, procedurelevel, and state-level factors on 90-day costs while controlling for other covariates. The final regression model included the following variables: age, sex, location of surgery, fracture morphology, type of fracture, use of ankle arthroscopy, concurrent syndesmotic fixation, comorbidities, and state. Results from multivariate regression analyses have been reported as adjusted marginal cost impacts (+/ ) in US dollars, along with standard errors and respective P values. For state-level analyses, comparison was made by using Michigan as a reference. For all statistical purposes, a value of P < .05 was considered significant. All analyses were performed by using the PearlDiver research software, which uses R statistics at the back end to conduct and provide statistical analyses/outputs to users.TagedEn
TagedH1ResultsTagedEn TagedPAfter the application of inclusion/exclusion criteria, a total of 6499 patients were included in the study. The 90-day average reimbursement for the 6499 ankle fractures undergoing ORIF was $15,023 § $15,091 (Table 1). The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 § $1060. Individuals aged <65 or ≥70 years had significantly higher costs (Table 2). The highest marginal cost impacts for age, in decreasing order of effect, were for individuals aged ≥85 years (+$2568; P < .001), 80 to 84 years
TagedH1DiscussionTagedEn TagedPAlthough bundled payments are gaining popularity across the healthcare landscape, a lot of controversy still shrouds these
TagedEnTable 3
Marginal impact of procedural-level factors on 90-day reimbursements after controlling for age, sex, comorbidities, and state
Location of surgery Inpatient Outpatient Fracture morphology Unimalleolar Bimalleolar Trimalleolar Type of fracture Open Closed Use of ankle arthroscopy Syndesmotic injury/fixation * Significance at P < .05.
Number of patients (%)
Reimbursement adjustment (+/−)
4724 (72.7%) 1775 (27.3%)
+$5577 § $410 Ref.
1417 (21.8%) 3130 (48.2%) 1952 (30.0%)
Ref. +$437 § $464 +$1082 § $498
984 (15.1%) 5515 (84.9%) <11 (<0.2%) 611 (9.4%)
+$911 § $497 Ref +$2683 § $4470 +$2822 § $607
P value <.001*
.346 .030* .067 .548 <.001*
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TagedEnTable 4
TagedEnTable 5
Marginal impact of costs by individual comorbidities
Comorbidity Congestive heart failure Ischemic heart disease Hyperlipidemia Hypertension Parkinson disease Alzheimer disease Cerebrovascular/stroke Chronic obstructive pulmonary disease Diabetes mellitus Hypothyroidism Chronic kidney disease Chronic liver disease Malignancy Inflammatory disorder Coagulopathy Hypercoagulopathy Osteoporosis Obesity Anemia Alcohol use Tobacco use Drug abuse Depression/bipolar Anxiety disorder Malnutrition
7
Marginal impact of state-level variation on costs with the state of michigan taken as the reference
Number of patients (%)
Reimbursement adjustment (+/−)
P value
585 (9.0%) 1042 (16.0%) 1559 (24.0%) 3155 (48.5%) 58 (1.2%) 122 (1.9%) 403 (6.2%) 894 (13.8%)
+$2395 § $671 +$1261 § $530 −$2265 § $459 −$1743 § $408 −$1462 § $1875 +$1511 § $1321 +$4159 § $752 +$1932 § $536
<.001* .017* <.001* <.001* .436 .253 <.001* <.001*
1564 (24.1%) 695 (10.7%) 576 (8.9%) 97 (1.5%) 251 (3.9%) 153 (2.4%) 148 (2.3%) <11 (<0.2%) 803 (12.4%) 93 (1.4%) 755 (11.6%) 38 (0.6%) 247 (3.8%) 49 (0.8%) 653 (10.0%) 356 (5.5%) 27 (0.4%)
+$1243 § $457 −$1271 § $590 +$8897 § $667 +$1576 § $1475 +$1108 § $920 +$652 § $1171 +$4049 § $1198 −$1298 § $5014 −$591 § $552 +$5362 § $1498 +$3087 § $597 −$485§ $2342 −$235 § $952 −$688 § $2066 +$89 § $651 +$947 § $834 +$7908 § $2748
.007* .031* <.001* .285 .228 .578 <.001* .796 .284 <.001* <.001* .836 .805 .739 .256 .256 .004*
* Significance at P < .05.
alternative payment models. The concept of shifting the “risk” onto providers is one not keenly looked upon in orthopaedic trauma, given that most physicians strongly feel that the “one-size-fits-all” approach of bundled payments is not feasible when performing complex fracture fixations or taking care of sicker patients. By conducting a comprehensive cost analysis using a nationally representative database, our results reflect these concerns by rightfully identifying several patientlevel, procedure-level, and state-level factors that were responsible for producing significant variation in 90-day costs after surgical fixation of isolated ankle fractures.TagedEn TagedPThe significantly lower costs seen in patients aged 65 to 69 years compared to individuals <65 years old can be explained by Medicare eligibility. All individuals >65 years old are automatically eligible for Medicare coverage, but certain patients (such as those with disability, amyotrophic lateral sclerosis, and/or chronic kidney disease) who are <65 years old may also be eligible for Medicare. Given that these patients <65 years old are much more functionally dependent and/or sicker, it is not surprising they have significant higher risk-adjusted 90day costs compared with individuals aged 65 to 69 years.TagedEn TagedPPrior literature has shown outpatient ankle fracture surgery to not only reduce overall facility costs but also yield a protective effect in terms of lower rates of complications (14,15). With regard to the economics of outpatient facilities, Varacallo et al (12) analyzed 299 patients undergoing ORIF for isolated ankle fractures in ambulatory/outpatient centers and noted a similar cost reduction of around $6000 compared with inpatient surgery. Similarly, Bettin et al (16) analyzed 148 ankle fractures undergoing ORIF from a single institution and noted a 32% reduction in 90-day costs for individuals who received surgery in an outpatient setting. However, although there is an increasing push toward performing surgery in an outpatient setting, to reduce costs (17), providers should not overlook the need of inpatient care for individuals who ultimately would benefit from it.TagedEn TagedPOur findings also shine light on the need of risk-adjusting payments based on procedure heterogeneity and fracture morphology. Without a comprehensive risk adjustment based on fracture patterns and/or
State and District of Columbia
Number of patients (%)
Reimbursement adjustment (+/−)
Alabama Arkansas Kansas Oklahoma Louisiana Florida Tennessee Utah Iowa Missouri Mississippi Georgia North Dakota Montana Ohio South Carolina South Dakota Idaho Texas Nebraska Kentucky Virginia Nevada Pennsylvania Indiana Wisconsin North Carolina Maine New Mexico Minnesota Illinois Delaware West Virginia Colorado Arizona New Jersey Rhode Island Washington New Haven Connecticut Hawaii New York Vermont District of Columbia Massachusetts California Alaska Maryland Puerto Rico Michigan
162 (2.5%) 73 (1.1%) 85 (1.3%) 84 (1.3%) 87 (1.3%) 375 (5.8%) 203 (3.1%) 43 (0.7%) 84 (1.3%) 204 (3.1%) 96 (1.5%) 188 (2.9%) 17 (0.3%) 35 (0.5%) 249 (3.8%) 114 (1.8%) 26 (0.4%) 43 (0.7%) 501 (7.7%) 61 (0.9%) 117 (1.8%) 172 (2.6%) 32 (0.5%) 301 (4.6%) 189 (2.9%) 150 (2.3%) 261 (4.0%) 48 (0.7%) 31 (0.5%) 120 (1.8%) 301 (4.6%) 13 (0.2%) 51 (7.8%) 87 (1.3%) 111 (1.7%) 157 (2.4%) 20 (0.3%) 140 (2.2%) 30 (0.5%) 69 (1.1%) <11 (<0.2%) 284 (4.4%) 16 (0.2%) 14 (0.2%) 135 (2.1%) 403 (6.2%) <11 (<0.2%) 141 (2.2%) <11 (<0.2%) 254 (3.9%)
−$2001 § $1415 +$437 § $1869 −$274 § $1765 +$4002 § $1774 −$49 § $1751 $2057 § $1146 −$1384 § $1326 −$1992 § $2323 −$2308 § $1774 −$953 § $1323 −$4671 § $2538 −$1891 § $1356 −$1847 § $3537 −$4671 § $2538 −$1075 § $1258 +$326 § $1589 −$1567 § $2903 −$6025 § $2327 +$2556 § $1086 −$1281 § $2008 −$136 § $1574 −$1549 § $1391 +$6371 § $2645 −$640 § $1202 −$2196 § $1354 −$3061 § $1452 −$1120 § $1242 −$1829 § $2222 +$986 § $2679 −$2231 § $1561 +$212 § $1201 +$3801 § $4002 −$2683 § $2163 −$907 § $1751 +$2256 § $1604 +$3802 § $1433 +$130 § $3272 −$105 § $1484 +$329 § $2720 −$474 § $1919 +$2136 § $4777 +$1988 § $1218 −$300 § $3630 $84 § $3867 +$4497 § $1504 +$955 § $1130 +$5317 § $4780 +$3043 § $1480 −$9022 § $5397 Ref.
P value .157 .815 .876 .024* .976 .073 .297 .391 .193 .471 .066 .163 .601 .066 .393 .838 .589 .010* .019* .523 .931 .265 .016* .594 .105 .035* .367 .410 .713 .153 .860 .342 .215 .604 .160 .008* .968 .943 .904 .805 .654 .103 .934 .982 .003* .398 .266 .040* .095
* Significance at P < .05.
concurrent syndesmotic injury, providers may actually be disincentivized toward taking care of patients with complex cases. For instance, prior research has shown complex fracture patterns to be associated with higher risk of complications (18), readmissions (19), and subsequent costs (20). A bundle that does not account for fracture complexity will only end up causing major financial losses to healthcare systems (such as Level 1 trauma centers) that regularly receive complex fracture referrals from adjoining areas. Similarly, a lack of additional payment for treating concurrent syndesmotic injury in ankle fractures may also prevent providers from providing quality care to their patients.TagedEn TagedPThe cost impact of comorbidities often remains an overlooked corner in the era of value-based care. This is primarily because most health policy makers strongly believe that providers should try their best to preoperatively optimize individuals with modifiable comorbidities
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before surgery. However, although cost-containment strategies such as preoperative optimization of medically complex patients (e.g., weight loss in obese patients and/or reduction of glycated hemoglobin levels in individuals with diabetes) may be feasible in an elective total joint arthroplasty patient population, such options are not entirely available for physicians dealing with an urgent fracture. Such medically complex fracture patients may be considered “bundle busters” for whom the high costs of care would continually exceed the target price, resulting in unfair financial losses for the healthcare system. Given that different comorbidities have varying marginal cost impacts (e.g., +$1200 for diabetes mellitus vs +$7900 for malnutrition), our findings also highlight the importance of ensuring prospective payments are risk adjusted on the presence/absence of individual comorbidities. We believe that this form of risk adjustment is more robust in contrast to the Centers for Medicare and Medicaid Services use of broad comorbidity risk-assessment groups, such as “CC/MCC” modifiers, which do not completely account for all comorbidities (21), to risk adjust bundled payments in the comprehensive joint replacement model.TagedEn TagedPFinally, as bundled payments begin to be implemented nationally, health policy makers also need to take into account the significant state-level variation seen in 90-day costs. Briefly summarizing, in line with prior literature, a majority of the high-cost states appear to be concentrated in the Northeast (Massachusetts, Maryland, New Jersey), with the remaining high-cost areas being rather sporadic in distribution − Oklahoma and Texas in the South and Nevada in the West. Although the higher costs in the Northeastern states can be largely explained by general greater healthcare expenditures in that region, the higher costs in certain states such as Nevada and Oklahoma can be due to lower hospital market concentration (22) driving up payments.TagedEn TagedPThere are several limitations to the study. First, although we used a nationally representative data set of Medicare beneficiaries, these administrative data sets are prone to miscoding and billing errors. Second, the smaller sample sizes seen in certain variables (e.g., ankle arthroscopy and specific states such as Alaska and Hawaii) may be introducing a type II error in our study. We did not evaluate the marginal cost impacts of readmissions and post−acute care stays, because these are likely factors that Medicare will not use to risk-adjust prospective payments beforehand. In addition, because we were already analyzing the impact of individual comorbidities on 90-day costs, further including readmissions and post−acute care use would introduce multicollinearity in the study. Finally, in anticipation of expansion of current Centers for Medicare & Medicaid bundled-payment models, we only looked at elderly Medicare patients and not a younger cohort of patients who also experience ankle fractures and may have a different postoperative course of care and resource utilization. We also did not account for inflation over the time period, because that was beyond the scope of the study. It is likely that the calculated costs are underestimates of the actual costs in the current time period.TagedEn TagedPIn conclusion, with the use of a national administrative database of Medicare beneficiaries, the study highlights several important patientlevel, procedure-level, and state-level factors responsible for producing significant variation in 90-day costs. As the orthopaedic trauma world gradually evolves toward the adoption of bundled-payment models as a mainstay for reducing cost burden associated with lower extremity fractures, our findings facilitate discussion on the need of prior risk adjustment of prospective payment models to ensure that providers catering to complex ankle fractures and/or sicker patient populations are adequately reimbursed to prevent the creation of
financial disincentives and barriers of access to care in the US healthcare system.TagedEn TagedH1Supplementary MaterialsTagedEn TagedPSupplementary material associated with this article can be found in the online version at https://doi.org/10.1053/j.jfas.2019.05.004.TagedEn
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