During the past 20 years, increasing costs for total hip arthroplasty and total knee arthroplasty have outpaced increases in reimbursement.1 Implant costs can comprise up to 50% of Medicare's reimbursement for the entire procedure and hospitalization.2,3 This rise in costs without a commensurate rise in reimbursement threatens hospitals' financial stability and may therefore reduce patient access to care. In response, numerous cost-containment strategies have been proposed and implemented to reign in these costs. Value-based alternative payment models such as the Medicare bundled payment provide a fixed fee for all costs associated with a total joint arthroplasty, incentivizing all players to collaborate to provide better quality care at lower cost.4 Many hospitals have subsequently developed guidelines for implant use, restricting access to more expensive or newer implants.
Gain-sharing attempts to realign hospital and physician incentives by compensating surgeons for making costeffective decisions that yield savings for the hospital.4 Compensation may be in the form of bonus payments, additional personnel resources such as physician assistants, research funds, or another item of value to the physician or the department.5 Although surgeons may reap small rewards from gain-sharing, they may have less autonomy to choose the implants they believe are best for their patients.
A second strategy to contain implant costs while also promoting patient autonomy is to permit patients to pay the incremental cost of more expensive implants. Such cost may exceed the price ceiling set by hospitals or insurers. This is not currently permitted in the United States, but surgeons and economists have expressed interest in this approach.6,7 Permitting patients to pay for more expensive implants that would not normally be included on the hospital “formulary” is analogous to the option patients already have to seek “out of network” providers for an extra fee.
Surgeon alignment is critical for a cost-containment strategy to be effective, yet little has been published on surgeons' perspectives on payment models.8 Therefore, the authors sought to understand arthroplasty surgeons' perspectives on 2 cost-containment strategies: (1) gainsharing programs in which surgeons receive a portion of the hospital's cost savings for an episode of care with lower implant cost, and (2) permitting patients to pay incremental costs associated with more expensive implants that might otherwise be unavailable to them.
The authors hypothesized that surgeons would prioritize retaining the freedom to choose an implant for their patients over financial incentives, and that surgeons would be open to patients contributing toward the cost of “premium” implants in the future.
Materials and Methods
An email survey was sent to active members of the International Congress for Joint Reconstruction as of April 2016. The survey posed 6 demographic questions (Table 1) and 12 binary (yes/no) questions addressing surgeon attitudes about implant technology and costs (Table 2). All survey responses were included and analyzed using Stata version 13.1 software (StataCorp LP, College Station, Texas). Descriptive analyses were performed. Univariate analyses were performed using chi-square tests to identify attitudes significantly associated with willingness to forgo gain-sharing and with the belief that patients should be allowed to pay for more expensive implants. Simple linear regression was used to assess associations between surgical volume and attitudes toward cost-containment strategies. Nonresponse bias was assessed by comparing early responses with late responses in terms of demographics and questionnaire items.9 Late responses were defined as those received more than 24 hours after sending the survey.
Survey Questions and Responses
A total of 899 surgeons opened the email, indicating receipt of the survey. A total of 126 surgeons responded to the survey (14% of recipients). Respondents were evenly distributed across age groups (Table 1). Few respondents were 34 years or younger (4.7%) or 65 years or older (6.5%). A total of 64.2% of the surgeons had been in practice at least 11 years. Most (93.4%) of the respondents performed at least 70 total joint arthroplasty procedures annually. Just more than 70% performed at least 120 total joint arthroplasty procedures annually, and just more than 39% performed more than 250 total joint arthroplasty procedures annually. Respondents practiced in all 5 regions of the United States: Northeast (25.7%), Midwest (23.8%), South (32.4%), Mountain (6.7%), and Pacific (11.4%). The most common practice type was group orthopedic practice (41.4%). Urban (39.2%) and suburban (43.1%) practice settings were more common than rural (17.7%) practice settings. Response times were analyzed to detect any potential source of bias. Fifty percent of responses were received within 24 hours of disseminating the survey. Late responses (>24 hours after dissemination) were not significantly associated with demographic factors or questionnaire items.
Responses to the questions about implants, technology, and costs are summarized in Table 2. Slightly more than half (53.7%) of the respondents' institutions had guidelines in place for arthroplasty implant use. Approximately 77% believed that premium products do advance technology in orthopedics. Although most (57.6%) did not believe that new implants should be listed as experimental, 66.7% believed that patients should be informed that new implants are not yet supported by long-term studies or registry data. Furthermore, 67% supported restricting new implants to a small group of surgeons for a trial period prior to making them widely available.
More than half (53.2%) of the surgeons responded that surgeons should involve their patients in implant selection. Surgeons who believed patients should be involved were 13.8 times more likely to actually involve patients in implant choice (95% confidence interval, 4.6–41.7; P<.001). Although 45.1% reported that they actually do involve their patients in implant selection, only 27.3% reported involving patients in the choice of bearing surface for total hip arthroplasty. Small majorities believed that implant companies should be allowed to charge a premium for new implant technology (56.4%) and that surgeons should inform patients about implant costs (60%).
Many (66.7%) of the surgeons were willing to forgo gain-sharing incentives in exchange for more freedom to choose which implants they used. Chi-square tests showed that surgeons were more likely to give up gain-sharing in exchange for more control over implant selection if they also believed that premium products advance technology in orthopedics (P=.040). Surgeons also tended to be more likely to forgo gain-sharing if they had answered that they preferred not to discuss implant costs with patients (76% vs 67%, P=.094). Willingness to forgo gain-sharing was not associated with demographic factors (ie, age, years in practice, arthroplasty volume, region, practice type, or practice setting).
Most (76.9%) of the surgeons believed that patients should be allowed to pay incremental costs for new technology or premium implants. Surgeons who believed that companies should be allowed to charge more for new technology were also more likely to believe that patients should be allowed to pay the extra expense for that technology (odds ratio, 8.8; 95% confidence interval, 2.7–29.0; P<.001). Similarly, surgeons were more likely to support giving patients the option to pay extra for a premium implant if they also believed in discussing costs with patients (odds ratio, 3.9; 95% confidence interval, 1.5–10.4; P=.004) or had higher surgical volume (5.1% higher odds; 95% confidence interval, 1.1%–9.2% for every 10 incremental total joint arthroplasty procedures performed annually; P=.013). Whereas only 57% of surgeons performing fewer than 70 total joint arthroplasty procedures annually supported patient cost-sharing, 63% of surgeons performing more than 250 total joint arthroplasty procedures annually supported patient cost-sharing.
The authors sought to understand surgeons' perceptions and current practices regarding the use of novel implants. Although a slight majority (55%) of surgeons reported discussing implant choice with their patients, only 27.3% reported discussing total hip arthroplasty bearing surfaces, specifically the choice between ceramic and cobalt-chrome femoral heads. Because both bearing surfaces have long track records supported by substantial evidence on both clinical outcomes and cost-benefit analyses, surgeons may be more likely to make this choice themselves or to accept institutional guidelines.10–13 As concerns rise about trunnionosis associated with metal heads and evidence emerges supporting the use of ceramic heads,14–16 it is possible that surgeons may increase patient involvement in bearing choice.
The majority (76.9%) of orthopedic surgeons believed that new technology is important to advancing the field of orthopedics. Indeed, new technologies such as ceramic-on-polyethylene bearings17 and highly cross-linked polyethylene18,19 have dramatically improved implant longevity and patient outcomes.
However, most respondents advised proceeding with some degree of caution—either through restricting new implants to a small group of investigators prior to making them available to all surgeons (67%) or through informing patients that these implants are not yet supported by long-term clinical data (66.7%). The authors agree that restricting implants to new investigators for a trial period would yield short-term clinical data that could help to ensure the safety of new implants. Most orthopedic devices reach the US market through the Food and Drug Administration's 510(k) process, which grants market approval to devices that purport to be “at least as safe and effective” as a legally marketed device.20 The 510(k) process offers patients expedited access to novel technology in part because the Food and Drug Administration does not require time-intensive and costly prospective clinical trials for these devices. Although a brief trial period would not have been sufficient to detect historical problems such as metallosis associated with metal-on-metal articulations or trunionosis associated with large metal heads, it might help to detect early catastrophic failures of new implants in the future.
However, catastrophes such as the metal-on-metal hip arthroplasty recalls from 2008 to 201221 might have been prevented if such a monitoring period had been implemented. Laboratory data showing 20 to 100 times lower wear rates for metal-on-metal bearings22 generated great enthusiasm about the potential for increased longevity with metal-on-metal total hip arthroplasties, leading to implantation of more than 1 million metal-on-metal total hip arthroplasties from 1996 to 2014.23 Unfortunately, the metallosis and catastrophic wear generated in vivo went undetected until registry data revealed 2-fold higher early revision rates.24–26 This example reveals the importance of clinical data monitoring and highlights the potential benefits of a monitoring period before widespread release of new technologies. Given that devices currently do not undergo such a review period, the authors suggest that surgeons inform patients of the possibility that new technologies may have unforeseen shortcomings.
The authors also sought to understand surgeons' perspectives on 2 financial models that have been proposed to improve the cost-effectiveness of total joint arthroplasties: (1) gain-sharing programs in which surgeons receive a portion of the hospital's savings for delivering cost-effective care, and (2) permitting patients to pay incremental costs associated with more expensive implants that might not otherwise be offered. The authors found that 66.7% of arthroplasty surgeons were willing to give up gain-sharing in exchange for freedom to choose which implants they use, and 76.9% of surgeons believed that patients should be allowed to pay for more expensive implants that otherwise might not be offered. Together, these findings suggest that many surgeons believe that both surgeons and patients should retain more autonomy in selecting total joint arthroplasty implants.
Willingness to forgo gain-sharing in exchange for more control over implant choice was common across all geographic regions, practice types and settings, and years of surgical experience. There was no difference in willingness to give up gain-sharing between surgeons whose institutions did have implant use guidelines and surgeons whose institutions did not. Therefore, willingness to give up financial upside is not related to whether surgeons have had actual experience with implant restrictions or gain-sharing in their own institutions. In contrast to a previous survey of American Association of Hip and Knee Surgeons members in which 79% expressed concern about uncertainty surrounding gain-sharing,27 the current authors found that most surgeons were more concerned with retaining autonomy and did not care as much about financial benefits. Overall, the current data show that many surgeons prioritize patient beneficence and surgeon autonomy above personal financial gain.
Surgeons who highlighted that new implants advance technology in orthopedics were more likely to give up gain-sharing to retain control over implant selection. Although not statistically significant (P=.094), a trend was found that surgeons who prefer not to discuss implant costs with patients may also be more willing to give up gain-sharing. A possible explanation is that these surgeons may have stronger implant preferences, which are unlikely to be influenced by patient input or financial incentives.
The authors found that most (76.9%) of the surgeons supported allowing patients to co-pay the additional cost for premium implants that might not otherwise be permitted by hospitals or insurers. Surgeons with higher annual surgical volume, those who believed that implant companies should be allowed to charge more for new technology, and those who supported discussing costs with patients were all significantly more likely to support patient cost-sharing.
Although the US payment and reimbursement system does not currently permit patients to purchase or directly contribute toward specific orthopedic implants, patients have expressed interest in this option. In a survey of patients with arthritis, 45% stated that they would be willing to pay an extra co-pay for an implant with 10 additional years of longevity.6,28 In this and another similar study,7 patients said they would be willing to pay $763 to $2440 additional for this increased longevity. Not surprisingly, patients with higher income were much more willing to pay an added co-pay for increased longevity. This highlights the ethical concern that permitting co-pays for premium implants could increase disparities in the quality of and access to health care. On the other hand, a benefit of permitting patient cost-sharing is that it would promote patient autonomy and potentially enhance shared decision-making.
The primary limitation of this study was the low response rate (14%, 126 of 899). Email surveys without financial incentives are associated with lower response rates among surgeons.29 However, an assessment of potential nonresponse bias, as described by Halbesleben and Whitman,9 showed that this was likely not large enough to alter the study conclusions, as late responders did not significantly differ from early responders on demographic characteristics or questionnaire items. Because late responders can serve as proxies for nonresponders, this implies that the results would not be substantially altered and are therefore generalizable to a broader audience. Furthermore, demographics of the respondents were similar to those reported in other surveys of arthroplasty surgeons.27 A variety of regions and practice types were represented, suggesting that these findings should be applicable to other US arthroplasty surgeons.
Another limitation was that because this survey assessed surgeons' perspectives but not their actual decisions, it is possible that true surgeon behavior may differ from the views expressed. However, because patient cost-sharing has not yet been implemented in orthopedics, and because hospitals do not disclose the details of their gain-sharing programs, surveys are currently the optimal method to study these issues.
Although most arthroplasty surgeons believe that technological innovation advances the field of orthopedics, they support discussing the “unproven” nature of new implants with patients. Most respondents prioritized patient beneficence and surgeon autonomy above personal financial gain. As bundled payment initiatives expand, hospitals will need to address implant costs to ensure that they remain solvent. These data reveal that many arthroplasty surgeons support alternative payment models that permit both the surgeon and the patient to retain autonomy regarding implant selection.
- Mendenhall S. Hip and knee implant prices rise. Orthopaedic Network News. 2006; 17(1):1.
- Rana AJ, Iorio R, Healy WL. Hospital economics of primary THA decreasing reimbursement and increasing cost, 1990 to 2008. Clin Orthop Relat Res. 2011; 469(2):355–361. doi:10.1007/s11999-010-1526-y [CrossRef]
- Healy WL, Rana AJ, Iorio R. Hospital economics of primary total knee arthroplasty at a teaching hospital. Clin Orthop Relat Res. 2011; 469(1):87–94. doi:10.1007/s11999-010-1486-2 [CrossRef]
- Greenwald AS, Bassano A, Wiggins S, Froimson MI. Alternative reimbursement models: bundled payment and beyond. AOA critical issues. J Bone Joint Surg Am. 2016; 98(11):e45. doi:10.2106/JBJS.15.01174 [CrossRef]
- Healy WL. Gainsharing: a primer for orthopaedic surgeons. J Bone Joint Surg Am. 2006; 88(8):1880–1887.
- Schwarzkopf R, Katz JN, Chen SP, Dong Y, Donnell-Fink LA, Losina E. Patients' willingness to contribute to cost of novel implants in total joint arthroplasty. J Arthroplasty. 2014; 29(9)(suppl):143–146. doi:10.1016/j.arth.2014.02.039 [CrossRef]
- Tucker JA, Scott CC, Thomas CS, O'Connor MI. Patient perception of Medicare reimbursement to orthopedic surgeons for THA and TKA. J Arthroplasty. 2013; 28(8)(suppl):144–147. doi:10.1016/j.arth.2013.05.037 [CrossRef]
- Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH. Decreasing total joint implant costs and physician specific cost variation through negotiation. J Arthroplasty. 2014; 29(4):678–680. doi:10.1016/j.arth.2013.09.016 [CrossRef]
- Halbesleben JR, Whitman MV. Evaluating survey quality in health services research: a decision framework for assessing nonresponse bias. Health Serv Res. 2013; 48(3):913–930. doi:10.1111/1475-6773.12002 [CrossRef]
- D'Antonio JA, Capello WN, Naughton M. Ceramic bearings for total hip arthroplasty have high survivorship at 10 years. Clin Orthop Relat Res. 2012; 470(2):373–381. doi:10.1007/s11999-011-2076-7 [CrossRef]
- Wang S, Zhang S, Zhao Y. A comparison of polyethylene wear between cobalt-chrome ball heads and alumina ball heads after total hip arthroplasty: a 10-year follow-up. J Orthop Surg Res. 2013; 8:20. doi:10.1186/1749-799X-8-20 [CrossRef]
- Kim YH. Comparison of polyethylene wear associated with cobalt-chromium and zirconia heads after total hip replacement: a prospective, randomized study. J Bone Joint Surg Am. 2005; 87(8):1769–1776.
- Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics: the case of alternative bearing surfaces in total hip arthroplasty. J Bone Joint Surg Am. 2006; 88(4):706–714.
- White PB, Meftah M, Ranawat AS, Ranawat CS. A comparison of blood metal ions in total hip arthroplasty using metal and ceramic heads. J Arthroplasty. 2016; 31(10):2215–2220. doi:10.1016/j.arth.2016.03.024 [CrossRef]
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- Kiran M, Boscainos PJ. Adverse reactions to metal debris in metal-on-polyethylene total hip arthroplasty using a titanium-molybdenum-zirconium-iron alloy stem. J Arthroplasty. 2015; 30(2):277–281. doi:10.1016/j.arth.2014.06.030 [CrossRef]
- Kocagoz SB, Underwood RJ, MacDonald DW, Gilbert JL, Kurtz SM. Ceramic heads decrease metal release caused by head-taper fretting and corrosion. Clin Orthop Relat Res. 2016; 474(4):985–994. doi:10.1007/s11999-015-4683-1 [CrossRef]
- So K, Goto K, Kuroda Y, Matsuda S. Minimum 10-year wear analysis of highly cross-linked polyethylene in cementless total hip arthroplasty. J Arthroplasty. 2015; 30(12):2224–2226. doi:10.1016/j.arth.2015.06.053 [CrossRef]
- Karidakis GK, Karachalios T. Oxidized zirconium head on crosslinked polyethylene liner in total hip arthroplasty: a 7- to 12-year in vivo comparative wear study. Clin Orthop Relat Res. 2015; 473(12):3836–3845. doi:10.1007/s11999-015-4503-7 [CrossRef]
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- US Food and Drug Administration. Recalls: recalls specific to metal-on-metal hip implants 2016. https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm335775.htm. Accessed May 13, 2017.
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| 25–34||5 (4.7)|
| 35–44||39 (36.5)|
| 45–54||27 (25.2)|
| 55–64||29 (27.1)|
| ≥65||7 (6.5)|
|Years in practice|
| 1–5||16 (15.1)|
| 6–10||22 (20.8)|
| 11–20||26 (24.5)|
| 21–30||27 (25.5)|
| 31–40||14 (13.2)|
| >40||1 (1.0)|
| Retired from practice||0 (0)|
|Annual total joint arthroplasty volume|
| <30||2 (1.9)|
| 30–70||5 (4.8)|
| 71–120||24 (22.9)|
| 121–250||33 (31.4)|
| 251–500||36 (34.3)|
| >500||5 (4.8)|
| South||34 (32.4)|
| Northeast||27 (25.7)|
| Midwest||25 (23.8)|
| Pacific||12 (11.4)|
| Mountain||7 (6.7)|
|Type of practice|
| Group orthopedic practice||43 (41.4)|
| Academic||19 (18.3)|
| Hospital||19 (18.3)|
| Solo orthopedic practice||12 (11.5)|
| Multispecialty group practice||11 (10.6)|
| Suburban||44 (43.1)|
| Urban||40 (39.2)|
| Rural||18 (17.7)|
Survey Questions and Responses
| Does your institution have guidelines for implant use in total joint replacement?||57 (46.3)||66 (53.7)|
| Do premium products advance technology in orthopedics?||28 (23.1)||93 (76.9)|
| Should new implants be listed as experimental or unproven?||68 (57.6)||50 (42.4)|
| Should patients be informed that new implants are experimental or unproven?||39 (33.3)||78 (66.7)|
| Should the use of new implants be restricted to a small group of investigators?||38 (33)||77 (67)|
| Should we involve our patients in the implant choice?||52 (46.9)||59 (53.2)|
| Do you involve your patients in your implant choice?||61 (55)||50 (45.1)|
| Do you involve your total hip patients in the choice between cobalt-chrome and ceramic heads?||80 (72.7)||30 (27.3)|
| Should implant companies be allowed to charge a premium for newly introduced technology, such as a new total knee design?||48 (43.6)||62 (56.4)|
| Should you share information regarding the cost of implants with your patients?||44 (40)||66 (60)|
| Do you think patients should be able to pay the additional cost for new technology or high-performance implants?||25 (23.2)||83 (76.9)|
| Are you willing to forgo gain-sharing in your hospital to have the freedom to use the implants of your choice?||36 (33.3)||72 (66.7)|