Co-author Adam J. Schwartz, M.D., M.B.A., an assistant professor of Orthopaedic Surgery at the Mayo Clinic College of Medicine in Phoenix, Arizona, outlined the background of his study to OTW. “We see a number of patients who are age 65, just getting onto Medicare as their primary health plan, and we asked if a large proportion of these patients might have had their surgery earlier if they had appropriate coverage.”
“A large number of patients seem to wait for Medicare enrollment before deciding to have a joint replacement. Policy makers need to understand the additional financial burden that the public health care system assumes because under-insured patients wait until Medicare enrollment to have their total joint replacement. This is in addition to the added years of pain and disability endured by patients who cannot proceed with the surgery until it becomes affordable to do so.”
Schwartz and his colleagues used the 2014 Nationwide Readmission Database to determine the incidence of TJA. What they found was that the TJA incidence rates increased from age 64 to 65 as compared to the expected increase.
The researchers calculated pent-up demand by subtracting the expected from the observed difference in frequency of TJA. They also measured the costs of such pent-up demand. The authors determined excess cost by multiplying this value by the median cost of a primary TJA. They then used the Medicare Expenditure Panel Survey Household Component to compare out-of-pocket costs, access to care, and insurance coverage among patients aged 60-64 (group 1) and 66-70 (group 2).
According to Schwartz and his colleagues, “The expected and observed increases in TJA procedures from age 64 to 65 were 595 and 5,211, respectively, resulting in pent-up demand of 4,616 joint arthroplasties (1,273 THA and 3,343 TKA), and an excess cost of $55 million (range, $33 million-$70 million). Mean total out-of-pocket expenses for patients in group 1 were significantly greater ($1,578.39) than patients in group 2…”
“Understand that as your patients get closer to enrolling in Medicare, they are more likely to defer their surgery. There is a slowing in demand for joint replacement around age 63, 64, when patients approach enrollment. It is reasonable to explore these issues with patients and try to understand their concerns and some of the issues with their insurance companies. It is quite possible that they do not need to unnecessarily delay these needed procedures.”
