Outliers of total shoulder arthroplasty in the bundled payment era

The Centers for Medicare & Medicaid Services implemented the Bundled Payments for Care Improvement Advanced (BPCIA) Model that covers 90-day care episodes after select orthopedic procedures including anatomic or reverse ball-and-socket total shoulder arthroplasty (TSA/rTSA). This study investigated whether patients undergoing TSA/rTSA for nondegenerative processes incur higher costs than patients undergoing arthroplasty for degenerative processes.

A retrospective review was conducted of all patients at a single academic medical center enrolled in the BPCIA model for TSA/rTSA from October 1, 2018, through December 31, 2022. We investigated whether patients undergoing arthroplasty for nondegenerative indications accrued more 90-day postoperative costs compared to patients undergoing arthroplasty for degenerative processes. A Break-even ratio was calculated to determine the number of degenerative TSA/rTSA that would need to be performed to account for the increased expenditures associated with nondegenerative TSA/rTSA.

One hundred patients met inclusion criteria during the study period. Costs for TSA/rTSA due to nondegenerative indications exceeded bundle payment amounts at a significantly higher rate compared to degenerative indications (43% vs. 18%, P = .021). TSA/rTSA for nondegenerative indications was also associated with significantly higher total costs ($27,100 vs. $22,200, P = .014), significantly more postoperative emergency department visits (43% vs. 18%, P = .035), and longer hospital length of stay (2.2 vs. 1.6 days, P = .121). Break-even ratio analysis demonstrated 1.22-1.54 TSA/rTSA for degenerative indications need to be performed to equal the total spending of one TSA/rTSA for nondegenerative indications.

Patients undergoing shoulder arthroplasty for nondegenerative indications within the Centers for Medicare & Medicaid Services BPCIA bundled payments program were at greater risk for incurring higher costs than allocated target payments, as well as significantly higher costs when compared to patients undergoing arthroplasty for degenerative processes. We may need to consider the roles bundled-payment programs have for these patients.