Patient Out-of-Pocket Cost Burden With Elective Orthopaedic Surgery

Wesley M. Durand, MD; Carlos D. Ortiz-Babilonia, BS; Daniel Badin, MD; Kevin Y. Wang, BA; Amit Jain, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(14):669-675. 

In This Article

Abstract and Introduction

Abstract

Introduction: Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting.

Methods: This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate.

Results: In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA.

Conclusion: Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.

Introduction

Despite a reduction in the uninsured over the last decade,[1] as healthcare costs continue to rise,[2] patients are facing increasing financial burden for medical services.[3] The annual Kaiser Family Foundation Employer Health Benefits Survey found that the annual premiums for workers with employer-sponsored insurance have continued to rise over the past decade.[4] In addition to monthly insurance premiums, when undergoing medical procedures, patients are responsible for variable out-of-pocket (OOP) expenses including copayments, coinsurance, and deductibles, incurred during the episode of care. A previous study found that these OOP costs have continued to rise for a variety of outpatient surgical procedures.[5] In addition to being a source of financial stress, OOP costs can influence patients' decision to pursue elective surgical care.[6] Furthermore, the OOP cost burden may influence the timing of elective surgery, and evidence indicates that some patients may opt to delay surgery until they turn 65 years and become Medicare eligible and thus have lower OOP obligations.[7]

Nevertheless, the incidence of elective, orthopaedic surgeries has been rising over the past few years in both younger and older patients.[8–11] Traditionally, costs in the orthopaedic literature have been analyzed from the lens of providers (hospitals and surgeons) and payors (insurers) and not from the perspective of patients (direct OOP contribution). The reimbursement to surgeons has decreased in both commercial and public payors,[12] whereas the payments to hospitals have continued to rise[13] and resulted in rising orthopaedic surgical costs. Yet, relatively little is reported regarding OOP costs for patients receiving inpatient orthopaedic surgery. The aim of this study is to analyze the trends in patients' OOP cost burden for common, elective orthopaedic surgeries performed in the hospital inpatient setting for commercially insured patients.

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