Patient Perceptions of Reimbursement for Arthroscopic Meniscectomy and Anterior Cruciate Ligament Reconstruction

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1 Ptient Perceptions of Reimursement for Arthroscopic nd Anterior Crucite Ligment Reconstruction Kelechi R. Okoroh, MD; Roert A. Keller, MD; Nthn E. Mrshll, MD; Jonthn R. Lynch, MD; John-Michel Guest, BS; Terrnce Lock, MD; Brin Rill, MD strct Historiclly, ptient perceptions of surgeon reimursement hve een exggerted compred with ctul reimursement. There is limited informtion out ptient perceptions of physicin reimursement for rthroscopic meniscectomy nd nterior crucite ligment (ACL) reconstruction. This study evluted ptient perceptions of physicin reimursement for these procedures nd compred perceptions of helth cre reform etween urn nd suurn clinics. Surveys were given to 231 consecutive ptients, nd ptients were sked how much they elieved surgeon should e reimursed for rthroscopic meniscectomy nd ACL reconstruction s well s their perception of ctul Medicre reimursement to physicins. Ptients were then informed of the ctul reimursement rtes nd sked dditionl questions out helth cre reform. Survey responses were compred in n urn setting vs suurn setting. On verge, ptients reported tht surgeons should receive $8096 for meniscectomy nd $11,794 for ACL reconstruction. Ptients estimted tht Medicre pid physicins $5442 for meniscectomy nd $6667 for ACL reconstruction. In ddition, 65% of ptients elieved tht reimursement for meniscectomy ws too low, nd 57% of ptients elieved tht reimursement for ACL reconstruction ws too low. Fewer thn 2% of ptients elieved tht surgeon slries should e cut, nd 75% elieved tht orthopedic surgeons should e pid more for suspecilty trining. No differences were found in ptients perceptions of reimursement or helth cre reform etween urn nd suurn settings. Ptients perceived tht the vlues of meniscectomy nd ACL reconstruction were sustntilly higher thn current Medicre reimursement vlues nd tht surgeon slries should not e cut. [Orthopedics. 20xx; x(x):exxx-exxx.] The cost of helth cre nd the topic of helth cre reform hve received incresing politicl nd pulic scrutiny nd dete. Medicre hs continued to mke cuts to surgeon reimursement nd hs een the enchmrk y which ll other insurnce compnies set physicin reimursement schedules. 1-4 Becuse of these cuts nd medicl infltion, mny orthopedic surgeons hve contemplted opting out of Medicre. 3,4 In 2009, Americn Orthopedic Assocition memers were polled on current helth cre reform topics, nd 71% of respondents stted tht without Medicre reimursement reform, sustntil numer of orthopedic surgeons will opt out of the Medicre progrm in the coming yers, leving mny ptients with limited ccess to musculoskeletl cre. 4 Current physicin fee schedules used y Medicre do not ccurtely ssess physicin cost to prctice or ptients perceived vlue of the procedures. 3-9 These physicin fee schedules use reltive vlue units, which re often dopted y privte insurnce compnies nd ecome the stndrd reimursement vlue. 3 The uthors re from the Deprtment of Orthopedic Surgery, Henry Ford Hospitl, Detroit, Michign. The uthors hve no relevnt finncil reltionships to disclose. Correspondence should e ddressed to: Kelechi R. Okoroh, MD, Deprtment of Orthopedic Surgery, Henry Ford Hospitl, 2799 W Grd Blvd (CFP-6), Detroit, MI (krokoroh@gmil.com). Received: Jnury 15, 2016; Accepted: April 11, doi: / MONTH/MONTH 20xx Volume xx Numer x 1

2 A B C D E Figure: Ptient demogrphics, including ge (A), sex (B), previous knee surgeries (C), eduction level (D), income (E), nd insurnce type (F). P vlue indictes the difference etween clinic loctions (*P<.05). Arevitions: ACL, nterior crucite ligment; BD, chelor degree; GD, grdute degree; HMO, helth mintennce orgniztion; HSG, high school grdute; PPO, preferred provider orgniztion; TKA, totl knee rthroplsty. F It is uncler whether ptients hve n ccurte impression of Medicre reimursement to physicins. Previous studies of ptient perceptions of surgeon reimursement showed lrge discrepncy etween ptient perceptions nd ctul reimursement vlues. 5-7,10-13 Forn et l 6 nd Tucker et l 13 found tht ptients estimted physicin reimursement for totl knee rthroplsty nd totl hip rthroplsty t pproximtely 3 to 9 times the ctul reimursement. Ptients lso overestimted reimursement for common hnd procedures, such s open reduction nd internl fixtion of distl rdius frcture nd crpl tunnel relese, y fctor of pproximtely Ptients lso gretly overestimted reimursement for totl shoulder replcement nd rottor cuff repir. 7 Although ptient perceptions of physicin reimursement pper to e lrgely 2 Copyright SLACK Incorported

3 exggerted in multiple res of orthopedics, there is no current informtion on ptient perceptions of reimursement for rthroscopic knee surgery. Becuse rthroscopic knee surgery is the most common orthopedic procedure, the perceptions of ptients regrding reimursement for this procedure re importnt. 14 The current study evluted ptient perceptions of physicin reimursement for rthroscopic meniscectomy nd nterior crucite ligment (ACL) reconstruction. Further gols of the study were to determine the vlue tht ptients plced on ech procedure nd to compre ptient perceptions of reimursement sed on geogrphic fctors. The uthors hypothesis ws tht ptient perceptions of physicin reimursement for rthroscopic meniscectomy nd ACL reconstruction would e gretly exggerted compred with ctul reimursement nd tht these ssumptions would differ in ptients in n urn clinic compred with ptients in suurn clinic. Mterils nd Methods Prticipnts After pprovl ws otined from the institutionl review ord, ptients from 2 seprte sports medicine clinic loctions were voluntrily enrolled to complete the nonymous survey. One clinic site ws locted in suurn re, nd the other site ws locted in downtown urn center. All ptients who completed the survey responded nonymously vi n electronic device in the witing room efore evlution y the physicin. A nonphysicin sked ptients if they wished to tke the survey. Ptients were informed tht the survey contined no identifying informtion nd ws completely confidentil. Ptients were included in the study if they were scheduled for n orthopedic sports medicine clinic visit. Those younger thn 18 yers were excluded. Surveys were given to 231 consecutive ptients over 3-month period etween April 2015 nd June The survey sked respondents to provide sic demogrphic Opertion totl informtion, including ge, sex, income level, type of helth insurnce, nd level of eduction. Respondents were lso sked out previous knee surgeries. Prticipnts were sked to give their opinion of current helth cre regultions, including whether physicins re overpid, whether physicin slries should e cut, nd whether slries should e linked to outcomes, s well s the est wy to lower the costs of helth cre. Respondents were then sked the following questions out reimursement: Tle 1 Surgicl Reimursements Strtified y Clinic Type Medicre Reimursement Resonle Out of Fee Estimted Actul P Pocket Wht Reimursement Should Be $8096 $5442 $576 <.001 c $2286 $2719 Urn $9238 $5641 <.001 c $2653 $3457 Suurn $6635 $5183 <.010 c $1803 $1883 P etween loctions Anterior crucite ligment reconstruction totl.296 $11,794 $6667 $1013 <.001 c $3517 $4885 Urn $12,126 $6794 <.001 c $4102 $5937 Suurn $11,366 $6503 <.001 c $2764 $3689 P etween loctions Coronry rtery ypss grft totl.998 $28,596 $18,192 $2250 <.001 c Urn $28,963 $17,136 <.001 c Suurn $28,133 $19,539 <.001 c P etween loctions Appendectomy totl.856 $10,353 $6733 $660 <.001 c Urn $11,274 $7985 <.001 c Suurn $9187 $5134 <.001 c P etween loctions.389 Vlues listed s mens in US dollrs. Difference etween estimted nd ctul reimursement unless otherwise stted. c Sttisticlly significnt (P<.05). 1. Wht do you think is resonle fee tht n orthopedic surgeon should receive to perform meniscectomy? (A knee scope surgery with removl of torn meniscus [crtilge]) 2. How much do you estimte tht Medicre ctully pys n orthopedic surgeon for performing meniscectomy? (A knee scope with removl of torn meniscus [crtilge]) 3. Wht do you think is resonle fee tht n orthopedic surgeon should re- MONTH/MONTH 20xx Volume xx Numer x 3

4 ceive to perform n ACL (nterior crucite ligment) reconstruction surgery? 4. How much do you estimte tht Medicre ctully pys n orthopedic surgeon for performing n ACL reconstruction surgery? Respondents were then sked wht they would e willing to py for ech of the surgeries. As n internl control, ptients were sked out reimursement for surgeons performing ppendectomy nd coronry rtery ypss grft Tle 2 Helth Cre Reform Perceptions y Geogrphic Clinic Loction Clinic Site Perception Overll Urn Suurn P Are physicins overpid? No 87% 86% 89%.56 Yes 13% 14% 11% Should physicins slries e cut? No 88% 87% 88%.99 Yes 12% 13% 12% Should slries e linked to outcomes? No 61% 60% 62%.90 Yes 39% 40% 38% Wht is the est wy to lower helth cre costs? Decrese drug nd device mnufcturer reimursement 79% 76% 82%.65 Decrese hospitl reimursement 12% 14% 11% Decrese physicin reimursement 2% 2% 1% Other 7% 8% 6% Is it importnt tht your surgeon hs suspecilized trining? No 18% 19% 16%.73 Yes 82% 81% 84% Do you think surgeon with specilized trining should receive dditionl pyment? No 25% 27% 22%.46 Yes 75% 73% 78% Wht is resonle dditionl pyment surgeon with specilized trining should receive? Vlues listed s percentge of ptients. Difference etween clinic sites. $1478 $1722 $ procedures. After ptients completed the first pge of the survey, they proceeded to the second pge. Progrmming did not llow review of the first pge. The second pge of the survey then told respondents, Current Medicre insurnce reimursement to physicin is: Knee scope/meniscus surgery (meniscectomy)-$ nd Current insurnce reimursement to physicin is: ACL reconstruction-$ They were then sked to ctegorize ech mount s very low, somewht low, out right, somewht high, or very high. Then they were sked wht they elieved the reimursement should e. Finlly, respondents were sked whether suspecilty trining of their physicin ws importnt to them nd whether physicins should receive dditionl py for suspeciliztion. If they nswered yes, then they were sked how much extr the physicin should e pid for this dditionl trining. Dt Collection Survey responses were collected electroniclly nd entered into dtse. No specific confidentil helth informtion ws collected, nd ll surveys were recorded nonymously. Sttisticl Anlysis Before finl nlysis, surveys were evluted, nd responses were omitted tht differed from the verge y more thn 3 stndrd devitions. All nlyses were performed with R softwre (R core tem, 2012; R Foundtion for Sttisticl Computing, Vienn, Austri). Ctegoricl vriles were tested with chi-squre tests. Continuous vriles for comprison etween urn nd suurn loctions were tested with Mnn- Whitney U nonprmetric 2-group comprison. To test perceptions of reimursement vs ctul reimursement, 1-smple Wilcoxon tests were performed. Finlly, nlysis of dt strtified y household income, eduction level, nd history of knee surgery ws done with Kruskl- Wllis testing. Results A totl of 231 ptients (53% women, 47% men), 127 in n urn clinic nd 104 in suurn clinic, completed the survey. Nine ptients declined to prticipte. Men ge of the respondents ws 55.5 yers (rnge, yers). Of ptients who completed the survey, 33 percent (n=77) reported previous knee surgery. The suurn clinic hd significntly greter numer of respondents who were 4 Copyright SLACK Incorported

5 women, were older, nd hd history of meniscectomy/totl knee rthroplsty. Ptient demogrphics with sttisticl comprisons etween clinic loctions, including ge, sex, previous knee surgeries, eduction level, income, nd insurnce type, re shown in the Figure. On verge, ptients perceived tht resonle fee for meniscectomy would e $8096, pproximtely 14 times s much s is ctully reimursed ($576, P<.01). They perceived tht resonle fee for ACL reconstruction would e $11,794, pproximtely 11 times s much s is ctully reimursed ($1013, P<.01). Ptients estimted tht Medicre pid physicins $5442 for meniscectomy nd $6667 for ACL reconstruction. Ptients were willing to py $2286 for meniscectomy nd $3517 for ACL reconstruction (Tle 1). To reference these vlues compred with other surgicl procedures, ptients were sked wht they elieved ws n pproprite fee for coronry rtery ypss grft nd ppendectomy procedures. Ptients lso overestimted Medicre reimursement for these generl surgery procedures; responses re shown in Tle 1. After they were informed of the ctul reimursement for the procedures, 65% of ptients elieved tht reimursement for meniscectomy ws too low (somewht low, 36%; very low, 29%). On verge, these ptients elieved tht more pproprite vlue for reimursement would e $2719. In ddition, 57% of ptients elieved tht reimursement for ACL reconstruction ws too low (somewht low, 30%; very low, 27%). On verge, these ptients elieved tht more pproprite vlue would e $4885 (Tle 1). No significnt differences were found when ptient responses were compred etween the urn nd suurn clinic loctions. When sked whether surgeons re overpid, 87% of ptients nswered no nd 88% did not think tht surgeons slries should e cut. In ddition, 61% of ptients lso did not think tht surgeon slries should e linked to outcomes. When sked how helth cre costs should e decresed, most ptients stted tht reimursement to drug nd device compnies should e decresed (79%), with 12% elieving tht hospitl reimursement should e cut nd 2% stting tht surgeon reimursement should e decresed. Finlly, when sked whether orthopedic suspeciliztion is importnt, 82% of ptients stted tht it is, with 75% stting tht orthopedic surgeons should receive extr compenstion for the dditionl trining. On verge, these ptients elieved tht $1478 per procedure is n pproprite mount of dditionl compenstion (Tle 2). Responses were strtified sed on the demogrphic ctegories descried. Responses were lso compred etween the different ctegories in ech strtified group with nlysis of vrince. No significnt differences were found in responses etween ctegories in ny of the strtified groups (Tles 3-5). Tle 3 Reimursement Responses Strtified y Income Level Reimursement Question Overll <$25,000 $25,000 to <$75,000 Income $75,000 to <$150,000 >$150,000 P Resonle fee $8096 $9583 $6593 $9522 $ Estimted reimursement Willing to py Anterior crucite ligment reconstruction $5442 $7548 $4034 $7380 $ $2286 $2967 $1515 $2649 $ Resonle fee $11,794 $9453 $10,203 $14443 $14, Estimted reimursement Willing to py Vlues listed s mens in US dollrs. Difference etween income levels. $6667 $7750 $5518 $8423 $ $3517 $3337 $2495 $4735 $ Discussion As helth cre costs continue to rise nd helth cre policies continue to chnge, physicin reimursement will continue to e n importnt re of concern to helth professionls, policy mkers, nd ptients. Mny ptients ssume tht with the increse in helth cre spending in the United Sttes ech yer, surgeon reimursement lso rises. On the contrry, when djusted for infltion, since 1992 (the yer tht the resource-sed reltive vlue system ws implemented), reimursement for orthopedic surgicl procedures hs decresed y 28% (rnge, -62% to 13%). 3 Severl studies showed tht ptients consistently overestimte the mount of physicin Medicre reimursement, nd s Medicre reimursement continues to decline, this gp will likely continue to increse. 5-7,10-13 The study findings expnd on previous knowledge nd provide dt to support the ide tht ptients plce higher vlue thn wht is reimursed on the most commonly nd sixth most commonly performed proce- MONTH/MONTH 20xx Volume xx Numer x 5

6 Reimursement Question Resonle fee dures in orthopedic surgery, rthroscopic meniscectomy nd ACL reconstruction. 15 Studies of reimursement for totl hip rthroplsty nd totl knee rthroplsty Tle 4 Reimursement Responses Strtified y Highest Level of Eduction Attined Estimted reimursement Willing to py Anterior crucite ligment reconstruction Resonle fee Estimted reimursement Willing to py Overll Vlues listed s mens in US dollrs. Difference etween eduction levels. High School Grdute or Less Eduction Level Some College Bchelor Degree Grdute Degree $8096 $6419 $7910 $8244 $14, $5442 $5338 $5137 $4138 $ $2286 $1578 $2376 $1580 $ $11,794 $8427 $12,285 $12,590 $19, $6667 $5097 $7412 $5935 $ $3517 $2146 $3632 $2075 $ Tle 5 Reimursement Responses Strtified y History of Knee Surgery History of Knee Surgery Reimursement Question Overll No Surgery Surgery P Resonle fee $8096 $7888 $ Estimted reimursement $5442 $4938 $ Willing to py $2286 $1666 $ Anterior crucite ligment reconstruction Resonle fee $11,794 $12,345 $10, Estimted reimursement $6667 $6565 $ Willing to py $3517 $2552 $ Vlues listed s mens in US dollrs. Difference in ptients sed on surgicl history. suggested tht ptients overestimte physicin reimursement y s much s 9 times the ctul reimursement. 6,13 Those surveyed in the current study estimted P the vlue of meniscectomy nd ACL reconstruction t pproximtely 14 nd 11 times the ctul reimursement, respectively. Even fter they were informed of the ctul reimursement, ptients still elieved tht ctul reimursement should e t lest 5 times the current vlue. Previous studies did not sk ptients out their willingness to py for procedures out of pocket. Ptients in the current study were willing to py pproximtely 4 times the Medicre reimursement for meniscectomy nd pproximtely 11 times the reimursement for ACL reconstruction, demonstrting how undervlued these procedures re. Although the uthors hypothesized tht perceptions would differ etween ptients in urn nd suurn settings, no significnt differences were found when responses were strtified y clinic loction. When ptient responses were strtified y household income, level of eduction, nd history of knee surgery, no significnt differences in responses were found. Regrdless of income level, level of eduction, history of knee surgery, or clinic loction (urn vs suurn), ptients in the current study universlly overestimted physicin reimursement. With the structure of helth cre continuously chnging, it is importnt to tke into ccount ptients views on reform. Ross nd Luritsen 16 surveyed ptients out physicins py nd found tht 70% of ptients elieved tht physicins re overpid. In contrst, the current study found tht 87% of ptients did not elieve tht physicins re overpid nd 88% elieved tht physicin slries should not e cut. Rther, when sked how to solve current helth cre prolems, most ptients elieved tht reimursement to drug nd device compnies should e decresed. When evluting ptient perceptions of reimursement in shoulder surgery, Ngd et l 7 found tht 90% of ptients elieved tht surgeons with suspecilty trining should receive dditionl pyment. This finding is in greement 6 Copyright SLACK Incorported

7 with the current study, in which 75% of survey respondents elieved tht surgeons with suspecilty trining should receive dditionl pyment. Completing postresidency trining is ssocited with finncil risk. Gskin et l 17 evluted the finncil impct of suspecilty fellowship trining nd found tht it tkes the verge surgeon 13 yers to recoup the loss of income ssocited with completing n extr yer of sports medicine fellowship trining. The current findings suggest tht ptients elieve tht the extr finncil urden ssumed y surgeons to increse clinicl skill should result in compenstion t higher level. Limittions This study hd severl importnt limittions. The survey ws performed in the witing room of n orthopedic sports medicine office. This could result in potentil is in the dt collected ecuse ptient who hd good reltionship with physicin might e more likely to stte tht surgeons should e pid more nd vice vers. In n ttempt to control for this fctor, ptients were told tht no identifying dt would e otined, nd the survey ws uploded nd ersed from the screen immeditely fter completion. The uthors elieved tht certinty out confidentility would result in less is. The uthors could not control for ptient understnding of current medicl costs, which my hve led to differences in reimursement estimtes. However, most of the ptients were reltively well educted, with 66% ttending t lest some college. Finlly, only 18% of the ptient popultion ctully hd insurnce through Medicre or Medicid. Although this represents minority of the uthors ptients, the dt re still relevnt to the generl popultion ecuse most privte nd pulic insurers se their pyments on Medicre fee schedules nd regultions. 3 Therefore, regrdless of the insurnce crrier, most reimursement to physicins generted from this ptient smple ws influenced y Medicre reimursement vlues. Conclusion Ptients perceived tht the vlues of meniscectomy nd ACL reconstruction were sustntilly higher thn current Medicre reimursement. Most ptients elieved tht current reimursement is too low, nd on verge, ptients would e willing to py more thn the mount tht is currently reimursed. References 1. Reforming Medicre s Physicin Pyment System: Hering Before the Sucommittee on Helth of the Committee on Wys nd Mens U.S. House of Representtives. 110th Cong. 2nd Sess (2008). 2. Iglehrt JK. Medicre s declining pyments to physicins. N Engl J Med. 2002; 346(24): Hriri S, Bozic KJ, Lverni C, Prestipino A, Rush HE. Medicre physicin reimursement: pst, present, nd future. J Bone Joint Surg Am. 2007; 89(11): Bozic KJ, Crmer B, Alert TJ. Medicre nd the orthopedic surgeon: chllenges in providing, finncing, nd ccessing musculoskeletl cre for the elderly. J Bone Joint Surg Am. 2010; 92(6): Bdlni N, Forn JR, Phillips FM, et l. Ptient perceptions of physicin reimursement for spine surgery. Spine (Phil P 1976). 2013; 38(15): Forn JR, Sheth NP, Wrd SR, et l. Ptient perception of physicin reimursement in elective totl hip nd knee rthroplsty. J Arthroplsty. 2012; 27(5): Ngd S, Wiesel B, Aoud J, et l. Ptient perception of physicin reimursement in elective shoulder surgery. J Shoulder Elow Surg. 2015; 24(1): Wilur RH. Resource-sed prctice expense: how we got where we re tody. Ann Thorc Surg. 1997; 63(6): Hriri S, Bozic KJ, O Connor MI, Rush HE. Medicre prt B: physicin prticiption options. J Bone Joint Surg Am. 2008; 90(10): Brooks F, Pringe V, Tonge A, Lewis J, Mohnty K. Ptient estimtes of helthcre costs in trum nd orthopedics. Eur J Orthop Surg Trumtol. 2013; 23(6): Fowler JR, Buterugh GA. Ptient perception of physicin reimursement for common hnd surgicl procedures. Orthopedics. 2013; 36(9):e1149-e Mrtt JD, Ggnier JJ, Gomer MM, Reske SE, Hllstrom BR, Urquhrt AG. Ptients perceptions of the costs of totl hip nd knee rthroplsty. Am J Orthop (Belle Med NJ). 2015; 44(5):E135-E Tucker JA, Scott CC, Thoms CS, O Connor MI. Ptient perception of Medicre reimursement to orthopedic surgeons for THA nd TKA. J Arthroplsty. 2013; 28(suppl 8): Rutkow IM. Surgicl opertions in the United Sttes: then (1983) nd now (1994). Arch Surg. 1997; 132(9): Grrett WE Jr, Swiontkowski MF, Weinstein JN, et l. Americn Bord of Orthopedic Surgery prctice of the orthopedic surgeon: Prt-II. Certifiction exmintion cse mix. J Bone Joint Surg Am. 2006; 88(3): Ross CE, Luritsen J. Pulic opinion out doctors py. Am J Pulic Helth. 1985; 75(6): Gskill T, Cook C, Nunley J, Mther RC. The finncil impct of orthopedic fellowship trining. J Bone Joint Surg Am. 2009; 91(7): MONTH/MONTH 20xx Volume xx Numer x 7