The National Trend in Arthroplasty Surgery Location and the Economic Impact on Surgeons,Hospitals and ASCs

BackgroundWe sought to understand the magnitude of the shift in care settings (hospital inpatient, hospital outpatient, or ambulatory surgery center) for primary total joint arthroplasty (TJA) and its economic impact on surgeons and hospitals.MethodsWe measured the shift in care settings for primary TJAs using national 100% sample Medicare fee-for-service (FFS) claims data from January 2017 through March 2021. We also measured the percent of case being discharged the same day over time. We calculated the national average hospital payment rate by setting and the weighted average hospital payment rates based on the mix of inpatient and outpatient cases over time. We compared average facility and physician payment rate changes over time across common types of surgeries.ResultsBy the first quarter of 2021, 29% of Medicare FFS primary TJAs were performed hospital inpatient (down from 100% in 2017), 64% were performed hospital outpatient, and about 7% in an ambulatory surgery center. The percent of hospital-based primary TJAs that were discharged the same day increased from less than 2% in the first quarter of 2018 to over 18% in the first quarter of 2021. Medicare increased its payment rates for both inpatient and outpatient TJAs, which offset the impact of TJAs shifting from being performed inpatient to outpatient. The average Medicare payment rates for TJAs declined by more than they did for most other major procedures.ConclusionThere was a significant shift in care setting from hospital inpatient to hospital outpatient for Medicare primary TJAs. This shift led to lower average TJA payment rates to hospitals; however, the impact was attenuated due to the increasing Medicare reimbursement rates in each setting, particularly for outpatient cases.