A new paper published in the December 21, 2016 edition of The Journal of Bone and Joint Surgery tackles the issue of patient cost-sharing for total joint arthroplasty implants. The authors, all with the New York University Langone Orthopedic Surgery, discuss the ethics of having patients pay toward a pricier implant—one that would otherwise be nixed due to cost containment.
Cost-Sharing in TJA: Perhaps Let the Patient Decide
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Richard Iorio, M.D. told OTW, “Implants are priced according to industry marketing and newer implant technology is priced higher than tried and true, time tested implant technology. Patients often want newer, more expensive technology without knowing the full implications of this choice (newer technology may promise longer survivorship and higher levels of performance with no guarantees).”
“It is possible that patients contributing to implant cost would enhance their autonomy. With our current system, it is nigh impossible for patients to access information on implant quality or pricing. In addition, cost-sharing would alleviate the burden on hospitals and perhaps stimulate innovation among device manufacturers.”
“Such a move towards cost-sharing, however, should be led by physicians, who are naturally guided by their commitment to protect their patients. Cost-sharing gone wrong would involve over-the-top claims by marketers. We must ensure that patients have access to detailed data on implants…and that we have moved the needle toward the independent review of new technologies.”
“Hospitals and surgeons may have alignment relationships which encourage the use of the most cost effective implants rather than the newest technology. If patients wanted to pay the difference between what was recommended and what they desired, they should be able to if they wish to bear the cost and the surgeon is comfortable with that decision and the patient is informed of the risks in a shared decision making scenario.”
“Surgeons and patients aren’t always aware of the cost of implant choice, and the relationship between surgeons and hospitals. In a value-based healthcare environment these issues need to be transparent and patients should be given more information and autonomy regarding these decisions if they are willing to bear the financial burden.”
Additional authors are John J. Mercuri, M.D., Joseph A. Bosco, M.D., and Ran Schwartzkopf, M.D.
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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