Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
J Arthroplasty. 2023 Sep;38(9):1642-1651. doi: 10.1016/j.arth.2023.03.058. Epub 2023 Mar 25.
Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions.
A large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons.
For knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures.
The MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.
了解医疗机构提交的收费与 Medicare 支付之间的标记比率（MRs）对于高容量骨科手术的价格透明度和减少意外计费至关重要。本分析研究了 2013 年至 2019 年间 Medicare 受益人的主要和翻修全髋关节和膝关节置换术（THA 和 TKA）服务的 MRs，涉及医疗保健环境和地理位置。
使用医疗保健通用程序编码系统（HCPCS）代码查询了 2013 年至 2019 年间由骨科医生进行的所有 THA 和 TKA 手术的大型数据集，用于最常使用的服务。分析了每年的 MRs、服务数量、平均提交费用、平均允许支付和平均 Medicare 支付。评估了 MRs 的趋势。我们评估了 9 个 THA HCPCS 代码，每年平均提供 159297 例手术，平均由 5330 名外科医生进行。我们评估了 6 个 TKA HCPCS 代码，每年平均提供 290244 例手术，平均由 7308 名外科医生进行。
在研究期间，HCPCS 代码 27438（髌骨置换术与假体）的膝关节置换术的 MR 下降（8.30 降至 6.62；P=0.016），而 HCPCS 代码 27447（TKA）的 MR 中位数（四分位距[IQR]）最高（4.73[3.64 至 6.30]）。对于翻修膝关节手术，HCPCS 代码 27488（膝关节假体取出术；6.12[3.83-8.22]）的 MR 中位数（IQR）最高。虽然原发性和翻修性髋关节置换术均未发现趋势，但 2019 年原发性髋关节手术的中位数（IQR）MR 范围为 3.83（半髋关节置换术）至 5.06（先前髋关节手术转换为 THA），而 HCPCS 代码 27130（全髋关节置换术）的中位数（IQR）MR 为 4.66（3.58-6.44）。对于翻修髋关节手术，MR 范围为 3.79（股骨骨折或假体置换术的开放性治疗）至 6.10（THA 股骨部件的翻修）。威斯康星州的原发性膝关节、翻修膝关节和原发性髋关节手术的 MR 中位数（州内）最高（>9）。
与非骨科手术相比，原发性和翻修性 THA 和 TKA 手术的 MRs 高得惊人。这些发现代表着过高的超额收费，这可能给患者带来严重的经济负担，必须在未来的政策讨论中加以考虑，以避免价格通胀。
