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Influence of the Maryland All-Payer Model on Primary Total Knee Arthroplasties
Ronald E Delanois1, Jennifer I Etcheson2, Iciar M Dávila Castrodad1
1Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland.
Abstract:
In 2014, Maryland received a waiver for the Global Budget Revenue (GBR) program. We evaluated GBR's impact on patient and hospital trends for total knee arthroplasty (TKA) in Maryland compared with the U.S. Specifically, we examined (1) patient characteristics, (2) inpatient course, and (3) costs and charges associated with TKAs from 2014 through 2016.
Methods:
A comparative analysis of TKA-treated patients in the Maryland State Inpatient Database (n = 36,985) versus those in the National Inpatient Sample (n = 2,117,191) was performed. Patient characteristics included race, Charlson Comorbidity Index (CCI), morbid obesity, patient income status, and primary payer. Inpatient course included length of hospital stay (LOS), discharge disposition, and complications.
Results:
In the Maryland TKA cohort, the proportion of minorities increased from 2014 to 2016 while the proportion of whites decreased (p = 0.001). The proportion of patients with a CCI of ≥3 decreased (p = 0.014), that of low-income patients increased (p < 0.001), and that of patients covered by Medicare or Medicaid increased (p < 0.001). In the U.S. TKA cohort, the proportion of blacks increased (p < 0.001), that of patients with a CCI score of ≥3 decreased (p < 0.001), and the proportions of low-income patients (p < 0.001) and those covered by Medicare or Medicaid increased (p < 0.001). In both Maryland and the U.S., the LOS (p < 0.001) and complication rate (p < 0.001) decreased while home-routine discharges increased (p < 0.001). Costs and charges decreased in Maryland (p < 0.001 for both) whereas charges in the U.S. increased (p < 0.001) and costs decreased (p < 0.001).
Conclusions:
While the U.S. health reform and GBR achieved similar patient and hospital-specific outcomes and broader inclusion of minority patients, Maryland experienced decreased hospital charges while hospital charges increased in the U.S.
Level Of Evidence:
Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Insights
Maryland's Global Budget Revenue (GBR) program improved total knee arthroplasty (TKA) patient inclusion and outcomes, similar to U.S. trends. Notably, Maryland saw decreased hospital charges, unlike the U.S. where charges rose.
Area of Science:
- Health Economics
- Health Services Research
- Orthopedic Surgery
Background:
- Maryland implemented a Global Budget Revenue (GBR) waiver in 2014.
- Total knee arthroplasty (TKA) is a common orthopedic procedure with significant cost implications.
- Evaluating the impact of innovative payment models on healthcare delivery is crucial.
Purpose of the Study:
- To assess the impact of Maryland's GBR program on patient and hospital trends for TKA.
- To compare TKA patient characteristics, inpatient course, and costs in Maryland versus the U.S. from 2014-2016.
Main Methods:
- Comparative analysis using the Maryland State Inpatient Database and the National Inpatient Sample.
- Examined patient demographics (race, income, comorbidities), inpatient stay (length of stay, complications, discharge), and financial data (costs, charges).
- Statistical analysis to identify trends and differences between Maryland and the U.S. cohorts.
Main Results:
- Both Maryland and U.S. cohorts showed increased inclusion of minority and low-income patients, and a decrease in comorbidities.
- Length of stay and complication rates decreased in both regions, with an increase in home discharges.
- Maryland experienced a decrease in both costs and charges for TKA, while U.S. charges increased despite decreased costs.
Conclusions:
- Maryland's GBR program and U.S. health reform yielded comparable improvements in patient inclusion and hospital outcomes.
- A key distinction was Maryland's success in reducing hospital charges, a trend not observed nationally.
- The GBR model demonstrates potential for cost containment within TKA procedures.
