Utilization and Reimbursements of Primary Total Joint Arthroplasty in Ambulatory Surgical Centers: Analysis of Medicare Part A and B Databases.

Abstract

Background: Recent changes in Medicare reimbursement policies have facilitated the shift of primary total joint arthroplasty (TJA) volume to ambulatory surgical centers (ASC). The ASCs potentially provide a more cost-effective alternative to a hospital-setting TJA. This study investigated Medicare primary TJA utilization and reimbursement trends at ACSs compared to inpatient and outpatient settings between 2019 and 2022.

Methods: Medicare Part A and B claims data from the Centers for Medicare & Medicaid Services (CMS) databases were analyzed. Primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures were identified using Current Procedural Terminology (CPT) codes, Diagnostic Related Group (DRG) codes, and Comprehensive Ambulatory Payment Classification (C-APC) codes based on respective settings. The ASC utilization data was extracted based on year. Billing data for ASCs, hospital outpatient departments (HOPD), and inpatient TJA were compared. Monetary values were adjusted to 2022 dollars using the Consumer Price Index (CPI).

Results: From 2019 to 2022, 1,665,237 primary TJA claims were billed (TKA 1,079,846 claims; THA 585,391 claims), with a 6.1% increase in total utilization. The volume of ASC TJAs increased by 327.1% (TKA 193.8% from 2020 to 2022; THA 61.1% from 2021 to 2022). In the same period, average reimbursement for ASC TJAs rose by 3.9% (TKA 3.4%; THA 1.3%) but showed an 8.1% decline after adjusting for inflation (TKA -8.4%; THA -6.2%). By 2022, ASCs accounted for 8.6% of the total TJAs with the lowest reimbursement per procedure (TKA $8,472.3; THA $8578.7). This shift to ASCs corresponded with $235 million saved compared to inpatient settings and $137 million saved compared to HOPDs per year.

Conclusion: Our study highlights a marked increase in TJA volume at ASCs, with the procedure costing significantly less than HODP or inpatient TJAs. The findings underscore the growing acceptance of these centers as viable, cost-effective alternatives to traditional hospital settings. However, with the declining value of ASC reimbursements, continued monitoring of reimbursement policy is necessary to ensure the sustainability of these cost-effective ASCs for TJAs.