Pent-up demand for total shoulder arthroplasty prior to Medicare eligibility at age 65 years: evidence from a national patient database and national survey data.

BACKGROUND

Rising utilization rates of total shoulder arthroplasty (TSA) paired with an aging US population herald increased future economic burden. Previous research has demonstrated evidence of "pent-up demand" in health care (delaying medical care until financially able) accompanying insurance status changes. The purpose of this study was to determine pent-up demand for TSA in the years leading up to Medicare coverage at age 65 years while identifying key drivers underlying this trend, including socioeconomic status.

METHODS

The incidence rates of TSA were evaluated using the 2019 National Inpatient Sample database. The observed increase in incidence between the ages of 64 years (pre-Medicare group) and 65 years (post-Medicare group) was compared with the expected increase. The expected frequency of TSA was subtracted from the observed frequency of TSA to calculate pent-up demand. Excess cost was calculated by multiplying pent-up demand by the median cost of TSA. The Medicare Expenditure Panel Survey-Household Component was used to compare health care cost and patient experience between pre-Medicare patients (aged 60-64 years) and post-Medicare patients (aged 66-70 years).

RESULTS

The expected and observed increases in TSA procedures from age 64 years to age 65 years were 402, for an incidence rate increase of 0.13/1000 population (12.8% increase), and 820, for an incidence rate increase of 0.24/1000 population (27% increase), respectively. The 27% increase represented a sharp jump in comparison to the 7.8% annual growth rate between age 65 years and age 77 years. This resulted in pent-up demand between age 64 years and age 65 years of 418 TSA procedures and excess cost of $7.5 million. Mean total out-of-pocket expenses were significantly higher for the pre-Medicare group than for the post-Medicare group ($1700 vs. $1510, P < .001). Compared with the post-Medicare group, the pre-Medicare group exhibited a significantly higher proportion of patients who delayed Medicare care because of cost (P < .001), could not afford medical care (P < .001), had problems paying medical bills (P < .001), and were unable to pay medical bills (P < .001). Physician-patient relationship experience scores were significantly worse in the pre-Medicare group (P < .001). These trends were even stronger for low-income patients when data were broken down by income status.

CONCLUSIONS

Patients likely delay elective TSA until reaching Medicare eligibility at age 65 years, resulting in substantial added financial burden to the health care system. As US health care costs continue to rise, it will be crucial for orthopedic providers and policy makers to be aware of pent-up demand for TSA and its possible associated drivers, especially socioeconomic status.