Hospital, regional, and policy-level variations in shoulder arthroplasty prices: a Nationwide database study

Surgical reconstruction via hemiarthroplasty, anatomic total shoulder arthroplasty (aTSA), or reverse total shoulder arthroplasty (rTSA) is a common approach for treatment of various shoulder pathologies. Little is known about variations in negotiated payor rates for these procedures. The objective of this study was to examine hospital, regional, and policy-level factors associated with variations in negotiated rates for total shoulder arthroplasty (TSA) and hemiarthroplasty across the United States.

A cross-sectional analysis was performed with 2024 payor rate data from the Turquoise Health Database, using current procedural terminology codes for hemiarthroplasty (23470) and rTSA/aTSA (23472). Variables of interest were downloaded from publicly available sources, including hospital size, payor class, metropolitan/nonmetropolitan classification, regional household income, and Area Deprivation Index. State-level policies included Medicaid expansion status, certificate-of-need (CON) status, nurse practitioner scope-of-practice regulations, and participation in the All-Payer Claims Database (APCD). Multivariable linear regressions were used to assess associations between payor rates and variables of interest.

In total, 516,904 total rates were evaluated (256,422 hemiarthroplasty; 260,480 rTSA/aTSA). The unadjusted mean negotiated rate was $9,082 (standard deviation: $1,182) for hemiarthroplasty and $10,840 (standard deviation: $1,405) for TSA. In a separate multivariable analysis, the mean rate difference was $68 (95% CI: $35-$102). Hospital bed capacity was tied to variations in both cohorts. Metropolitan hospitals reported higher payor rates for both hemiarthroplasty (+$2,151.46) and rTSA/aTSA (+$879.73) in comparison to nonmetropolitan hospitals. Medicaid expansion was associated with higher rates for both cohorts, while increased nurse practitioner scope of practice, CON status, and APCD database participation were associated with lower rates (P < .001).

Shoulder arthroplasty negotiated payor rates show large variations and are associated with several factors, including hospital size, payor class, and regional factors. Mean TSA rates were $68 higher, a clinically insignificant amount. States with CON laws and APCD database participation have lower payor rates while states with Medicaid expansion have higher rates. These findings underscore significant variations in how hospitals and payors negotiate rates for shoulder arthroplasty, emphasizing the many factors that play a role in shaping surgical costs.