Original Research

Patients’ Perceptions of the Costs of Total Hip and Knee Arthroplasty

Am J Orthop. 2015 May;44(5):E135-E141

References

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Data from the survey and the electronic medical records were collected using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, Tennessee). Statistical analysis was performed with SAS Version 9.3 (SAS Institute, Cary, North Carolina). Data were screened before further analysis. Patients who provided nonnumeric responses in numeric response fields were excluded from further analysis. Numeric ranges were applied in subsequent analysis using the mean of the range. Implausible responses resulted in the removal of the entire encounter from subsequent analysis.

Demographic data used to define categories for further subgroup analysis are presented as percentages of the group. Medians, means, and interquartile ranges were calculated for all responses regarding reimbursement and cost. Differences in perceptions of reimbursement and cost based on subgroups, including procedure type, diagnosis, education level, and satisfaction, were calculated. Independent-samples Student t tests were used to determine the statistical significance of the differences detected.

Results

Of the 400 eligible patients seen at the first postoperative follow-up, 284 (71%) were enrolled in the study. Mean (SD) age was 62.6 (12.6) years. Of the 284 patients enrolled, 154 (54%) were female. Of the participants who reported their education and income, 125 (44%) had a bachelor’s degree or higher degree, and 68 (23.9%) reported income of more than $100,000 per year. The largest payers reported by patients were private insurance (80%) and Medicare (46%). Additional demographic details are listed in Table 1.

Of the 284 patients enrolled in the study, 159 (56%) had THA, and 88 (31%) had TKA (Table 2). Thirty-seven patients (13%) underwent revision procedures. Only 5 patients (2%) indicated they had reviewed their hospital billing statement from their most recent admission. Two hundred forty-two patients (85%) were satisfied or very satisfied with their procedure.

Regarding the implant used in their surgery, 216 patients (76%) indicated they did not know which company manufactured it. Of the 68 patients (24%) who named a manufacturer, 53 (78%) were correct in their selection (intraoperative records were checked). Patients indicated they thought the implant used in their surgery cost $6447 on average (95% CI, $5581-$7312).

On average, patients thought their surgeon was reimbursed $12,014 (95% CI, $10,845-$13,183) for their procedure, and they estimated that the hospital was reimbursed $28,392 (95% CI, $25,271-$31,512) for their perioperative care and that it cost the hospital $24,389 (95% CI, $21,612-$27,165) to provide it. Means, confidence intervals, medians, and interquartile ranges for parameters of reimbursement and cost are listed in Table 3. Seventy-one patients (25%) thought on average that the hospital took a net loss for each TJA performed, and 146 patients (51%) thought on average that the hospital generated a net profit for each TJA.

On average, patients thought surgeons were reimbursed $11,872 for a THA and $12,263 for a TKA. Patients also estimated a higher hospital cost (THA, $22,981; TKA, $26,998) and reimbursement (THA, $27,366; TKA, $30,230) after TKA than THA. These differences in perceptions of cost and reimbursement for THA and TKA appear in Table 4 and Figure 2.

Statistically significant differences were also found in perceptions of cost and reimbursement based on level of education and overall patient satisfaction. Patients with a bachelor’s degree or higher estimated physician reimbursement at $11,006, whereas patients with a lower level of education estimated reimbursement at $12,890. In addition, patients with a lower level of education gave estimates of hospital cost and reimbursement that were $7698 and $10,799 higher, respectively, than the estimates given by patients with a higher level of education (Table 5, Figure 3). Patients who were satisfied or very satisfied with their overall TJA experience estimated surgeon reimbursement at $11,673. Patients who indicated they were unsatisfied, very unsatisfied, or neutral regarding their overall experience gave a higher estimate of surgeon reimbursement: $14,317 (Table 6, Figure 4).

Because of the small number of enrolled patients who had revision surgery and the high variability in patient responses, there were no meaningful or statistically significant differences in perceptions of cost and reimbursement based on revision or primary surgery.

Patients also estimated substantial additional reimbursements to physicians for services included at no additional charge with the global surgical package. Median estimates were $300 for reimbursement to a physician making rounds in the hospital and $250 for reimbursement for an outpatient follow-up. Only 47 patients (17%) and 35 patients (12%) correctly indicated there is no additional payment for making rounds and outpatient follow-up, respectively. Estimates of these reimbursements varied by education level, procedure, and overall satisfaction (Tables 4–6).