Rizk Adam A, Singh Akash, Kobayashi E Fumina, Martino Brooks, Levin Jay M, Davis Daniel, Namdari Surena
Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
J Shoulder Elbow Surg. 2025 May 10. doi: 10.1016/j.jse.2025.03.035.
As the utilization of shoulder and elbow procedures increases, it is not clear whether the hospital reimbursement for these cases has proportionally increased in the United States. This study investigated trends in reimbursement for shoulder and elbow hospitalizations.
The Centers for Medicare and Medicaid Services Inpatient Utilization and Payment Public Use Files from 2015 to 2022 were retrospectively queried for all diagnosis-related groups (DRGs) (483, 507, 508, 510, 511, and 512) related to shoulder and elbow procedures, including primary and revision upper extremity arthroplasty cases. After adjusting for inflation to 2022 US dollars with the US Consumer Price Index, the mean, median, and standard deviation of the Medicare payments were determined to analyze the total number of procedures performed each year and over the study period. These same calculations were also performed for the submitted charges by hospital for the reported hospital expenses. A multiple linear mixed-model regression analysis and an analysis of covariance were performed to assess the change in reimbursement and charges over time for each code and the proportional rate of change between codes, respectively.
The inflation-adjusted average Medicare payment for DRG 483 per procedure decreased by $1295.57 (-7.2%) from $17,874.69 in 2015 to $16,579.12 in 2022. The inflation-adjusted average submitted charge for DRG 483 per procedure increased by $16,453.29 (19.1%) from $86,314.46 in 2015 to $102,767.76 in 2022. The inflation-adjusted Medicare payments for DRG 483 significantly decreased year-over-year over the study period (P < .001), showing consistent declines across years relative to the reference year.
The decrease in reimbursement for DRG 483, including revision upper extremity arthroplasty procedures, shows that fewer resources have been allocated for shoulder and elbow hospitalizations. These results necessitate further examination of Medicare payment algorithms to accurately account for case complexity in allocating fair reimbursement to hospitals for upper extremity procedures.
随着肩部和肘部手术的使用增加，在美国，这些病例的医院报销是否相应增加尚不清楚。本研究调查了肩部和肘部住院治疗的报销趋势。
回顾性查询2015年至2022年医疗保险和医疗补助服务中心的住院患者使用情况和支付公共使用文件，以获取与肩部和肘部手术相关的所有诊断相关组（DRG）（483、507、508、510、511和512），包括初次和翻修上肢关节成形术病例。使用美国消费者价格指数将其调整为2022年美元的通货膨胀后，确定医疗保险支付的平均值、中位数和标准差，以分析每年以及整个研究期间进行的手术总数。还对医院提交的报告医院费用进行了同样的计算。分别进行多元线性混合模型回归分析和协方差分析，以评估每个代码的报销和费用随时间的变化以及代码之间的比例变化率。
DRG 483每个手术经通货膨胀调整后的平均医疗保险支付从2015年的17874.69美元降至2022年的16579.12美元，减少了1295.57美元（-7.2%）。DRG 483每个手术经通货膨胀调整后的平均提交费用从2015年的86314.46美元增加到2022年的102767.76美元，增加了16453.29美元（19.1%）。在研究期间，DRG 483经通货膨胀调整后的医疗保险支付逐年显著下降（P <.001），相对于参考年份，各年呈持续下降趋势。
包括翻修上肢关节成形术在内的DRG 483报销减少，表明用于肩部和肘部住院治疗的资源减少。这些结果需要进一步检查医疗保险支付算法，以便在为上肢手术向医院分配公平报销时准确考虑病例复杂性。
