The Journal of Arthroplasty xxx (2014) xxx–xxx

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The Journal of Arthroplasty

j ourna l homepage: www.arth rop lasty journa l .o rg

Effect of Price Capitation on Implant Selection for Primary Total Hip andKnee Arthroplasty

Mario Farías-Kovac, MD, Caleb R. Szubski, BA, Mark Hebeish, DDS, Alison K. Klika, MS,Kirtishri Mishra, BS, Wael K. Barsoum, MDDepartment of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio

a b s t r a c ta r t i c l e i n f o

Conflicts of interest and source of funding: No finanthis study. Dr. Barsoumwould like to acknowledge the foto Stryker Orthopaedics; research support from StrykeSystems, Orthovita, DJO, Active Implants, The MedicinOhio; royalties from Stryker Orthopaedics, Zimmer, Exactoptions in OtisMed Corporation, Custom Orthopaedicmember at KEF Healthcare. No other authors have reledisclose.

The Conflict of Interest statement associated with thidx.doi.org/10.1016/j.arth.2014.02.020.

Reprint requests: Alison K. Klika, MS, Cleveland CliCleveland, OH 44195.

0883-5403/0000-0000$36.00/0 – see front matter © 20http://dx.doi.org/10.1016/j.arth.2014.02.020

Please cite this article as: Farías-Kovac M, eArthroplasty (2014), http://dx.doi.org/10.1

Article history:Received 2 January 2014Accepted 14 February 2014Available online xxxx

Keywords:total hip arthroplastytotal knee arthroplastyprice capitationimplant selectionpremium implants

While price capitation strategies may help to control total hip (THA) and knee arthroplasty (TKA) implantcosts, its effect on premium implant selection is unclear. Primary THA and TKA cases 6 months before andafter capitated pricing implementation were retrospectively identified. After exclusions, 716 THA and 981TKA from a large academic hospital and 2 midsize private practice community hospitals were reviewed.Academic hospital surgeons increased premium THA implant usage (66.5% to 70.6%; P = 0.28), whilecommunity surgeons selected fewer premium implants (36.4%) compared to academic surgeons, with nopractice change (P = 0.95). Conversely, premium TKA implant usage significantly increased (73.4% to 89.4%;P b 0.001) for academic surgeons. Community surgeons used premium TKA implants at greater rates in bothperiods, with all cases having ≥1 premium criterion.

cial support was received forllowing disclosures: consultantr Orthopaedics, Zimmer, Cooles Company, and the State ofech, and Shukla Medical; stockSolutions, and iVHR; board

vant financial relationships to

s article can be found at http://

nic, 9500 Euclid Avenue, A41,

14 Elsevier Inc. All rights reserved.

t al, Effect of Price Capitation on Implant Selec016/j.arth.2014.02.020

© 2014 Elsevier Inc. All rights reserved.

Over the last 2 decades, nontransformative, interval innovation oforthopedic implants has been the rule, with a focus on improvingfixation, motion, kinematics, stability, and durability [1]. Implantmanufacturers have spent billions of dollars on the development,marketing, and selling of their newest technologies as the demand forjoint arthroplasties have exponentially risen. In 2010, total hip (THA)and knee arthroplasty (TKA) accounted for 1,053,000 procedures,with an annual average increase of 4.3% in the number of cases from1993 to 2011 [2,3]. Driven by a rapidly aging population of babyboomers and a rise in the number of young patients (b65 years)receiving joint arthroplasty, primary THA and TKA have a projectedincrease of more than 174% and 673%, respectively, by 2030 [4,5].

Rising implant costs and diminishing reimbursement are a seriouschallenge to hospitals [6]. As orthopedic implants have evolved, therehas been an associated increase in cost. However, these changes aresignificantly outpacing Medicare's adjustments in reimbursement.From 1991 to 2005, there was a 156% rise in hip and knee implant list

priceswhile the averageMedicare payment to hospitals only increasedby 19% ($8489 to $10,109) [7]. In 2010, the cost of a primary hip andknee implant was $6398 and $5324, respectively, accounting forapproximately half of the total Medicare compensation for anuncomplicated primary joint arthroplasty at the time ($11,653) [8,9].

In 1997 orthopedic programs generated 25% of hospitals' profits,but by 2001 their financial impact had decreased to only 2% [10].Hospitals have developed and tested several strategies (i.e. implantselection standardization, group purchasing consignment, value-based purchasing, volume-incentive vendor contracts, single price/case price purchasing, physician gain sharing, establishment ofstandardized clinical and surgical pathways) to decrease implantand service costs [11–18]. Capitated pricing, in which a flat purchaseprice is negotiated for implant line items regardless of technology ormanufacturer, has emerged as a successful option for decreasingimplant costs in some health care institutions [13]. This model alsomaintains physician autonomy by offering a full list of implantoptions. Based on positive outcomes reported on experiences utilizingcapitated pricing strategies, our health system (which includes a largeacademic tertiary referral center and a number of community-basedsatellite hospitals) replaced a discount-based vendor-buyer systemwith a capitated pricing model for primary total joint implants in2011. This capitated pricing system assigned a single price cap forimplant line items, regardless of technology.

The purpose of this study was to evaluate whether the imple-mentation of this type of capitated pricing system affected usage ratesof primary THA and TKA premium implants (i.e. more expensive toproduce, newer technology) by salaried surgeons at a large academichospital. As physicians are no longer burdened by minimizing costs

tion for Primary Total Hip and Knee Arthroplasty, J

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for the patient or maximizing revenue for the hospitals undercapitated pricing, we hypothesized that physicians would be morelikely to select premium implants for their patients. A secondaryobjectivewas to compare the implant selection trends at the academichospital to those at two midsize private practice–based communityhospitals from the same health system. The surgeons at thesecommunity hospitals receive the same implant prices as the largeacademic hospital, yet their reimbursement systems are independentof the health system. Our secondary hypothesis was that privatepractice surgeons at these community hospitals are less likely to beaffected by this same implant purchasing model.

Methods

After approval by the institutional review board, all consecutiveprimary THA (CPT code 27130) and TKA (CPT code 27447) surgeries6 months before and after implementation of capitated pricing (7/1/2011) were retrospectively queried. Study sites included an academic,tertiary referral hospital and two community hospitals within thesame health system. Surgeon education regarding the new pricingpolicy was conducted for a 1-month period following implementa-tion, and these data were excluded from the analysis. This processestablished preprice (1/1/2011–6/30/2011) and postprice capitation(8/1/2011–1/31/2012) periods.

An initial cohort of 1881 cases (THA, n = 794; TKA, n = 1087)were identified that met the inclusion criteria. Simultaneous andstaged bilateral procedures were counted as two separate cases, onefor each limb. All staged bilateral procedures were retained in thestudy cohorts because there were no instances that spanned bothpreprice and postprice capitation periods. Exclusion criteria (Fig. 1)

Inclusion Criteria All consecutive primary total hip arthroplasty (THA) (CPT code 27130)

and total knee arthroplasty (TKA) (CPT code 27447) cases performed at a tertiary academic hospital and two community hospitals in following time

periods before and after price capitation was implemented (7/1/2011): Pre-capitated (1/1/2011-6/30/2011) Post-capitated (8/1/2011-1/31/2012)

*OMITTED 1 month surgeon education period (7/1/2011-7/31/2011)*

THA (n=794); TKA (n=1087)

Final THA Cohort (n=716) n=463 Academic Hospital n=253 Community Hospital

Analyzed variables: - Patient demographics - Hospital location - Implant fixation - Implant characteristics - Bearing surface

Excluded THA patients (n=78) - Procedure surgeon not represented

in both pre- and post-capitated periods (n=29)

- Bipolar prosthesis (n=14) - Complex pathologies (i.e. dwarfism,

bone tumor lesion, presence of previous hardware) (n=11)

- Metal-on-metal prosthesis (n=10) - Nickel allergy (n=8) - Unipolar prosthesis (n=3) - One-of-a-kind prosthesis (n=2) - Resurfacing procedure (n= 1)

Excluded TKA patients (n=106) - Procedure surgeon not represented

in both pre- and post-capitated periods (n=29)

- Total stabilizing system (n=20) - Nickel allergy (n=20) - Unicompartmental TKA (n=16) - Complex pathologies (i.e. dwarfism,

bone tumor lesion, presence of previous hardware, previous fracture) (n=15)

- Revision system (n=4) - Cobalt allergy (n=1) - Titanium allergy (n=1)

Final TKA Cohort (n=981) n=666 Academic Hospital n=315 Community Hospital

Analyzed variables: - Patient demographics - Hospital location - Implant fixation - Implant characteristics - Bearing surface

Fig. 1. Inclusion/Exclusion flow diagram.

Please cite this article as: Farías-Kovac M, et al, Effect of Price CapitationArthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.02.020

were established to remove cases that did not use primary total jointarthroplasty implants (e.g., unipolar, bipolar, unicompartmental) andto minimize situations in which the surgeon may not have hadcomplete freedom of implant selection (e.g., complex pathology,metal allergies, use of specific implant type, metal-on-metal designs).Cases performed by a surgeon who was not represented in bothpreprice and postprice capitation periods were excluded due to thepotential bias. After exclusions, a total of 463 THA and 666 TKA fromthe large academic hospital, and 253 THA and 315 TKA from the 2midsize community hospitals comprised the final study cohort.

A review of patient demographics and implant characteristics foreach case was performed using the electronic medical record.Demographics variables included age at surgery, gender, body massindex (BMI), and laterality. Using implant catalog numbers andoperative notes, the manufacturer, model, and material of eachimplant subcomponent were noted. Additionally, bearing surface,design characteristics, and component fit (i.e. cemented or press-fit)were collected.

Classification of each THA and TKA case's implants as premium ornon-premium was based on a slightly expanded version of that usedby Gioe et al [1]. Premium THA implants were defined by theexistence of one of the following bearing surfaces: second (2G) orthird generation (3G) highly cross-linked polyethylene liner with aceramic or oxidized-zirconium femoral head, ceramic liner with aceramic femoral head, or mobile-bearing system. Large femoral headsize and press-fit femoral stems were not regarded as premiumfactors. Second-generation highly cross-linked polyethylene linersincluded: AltrX Altralinked (DePuy, Warsaw, IN), Marathon (DePuy,Warsaw, IN), Longevity (Zimmer, Warsaw, IN), and R3 XLPE (Smith &Nephew, Memphis, TN). Third-generation highly cross-linked poly-ethylene liners included only X3 (Stryker, Mahwah, NJ). Premium TKAimplants were defined by the existence of at least one of the followingcriteria: mobile-bearing design, high-flexion design, oxidized-zirco-nium femoral component, and/or highly cross-linked polyethylenebearing surface.

Study data were collected and managed using REDCap (ResearchElectronic Data Capture), which is a secure, Web-based applicationdesigned to support data capture for research studies [19]. The datawere analyzed using R software (Version 3.0.2, Vienna, Austria).Continuous variables were described using means, standard de-viations, and 95% confidence intervals for means. Categorical variableswere described using counts and percentages. Continuous demo-graphic variables were compared using Welch's two-sample t-test.Categorical demographic variables were compared using Pearson'schi-squared test with Yates' continuity correction. Hip and kneepremium implant usage rates were compared between precapitationand postcapitation periods within the subsets defined by academicand community hospitals using logistic regression fit using general-ized estimating equations (GEE) to account for staged bilateral cases,on which observations cannot be assumed to be independent. Age,gender, and BMIwere included in thesemodels and so the resulting P-values testing for differences between precapitation and postcapita-tion are adjusted P-values. Rates of specific premium and non-premium implant subgroups were compared using Fisher's exact testfor count data or Pearson's chi-squared test, as appropriate, ignoringrepeated measures and the effects of age, gender, and BMI. Premiumand non-premium THA implant characteristics are mutually exclu-sive. Conversely, premium TKA characteristics are not mutuallyexclusive (i.e. a patient might receive an implant that possessesmore than one premium characteristic). Rates of usage of particularTKA implant types were therefore adjusted for multiplicity.

Results

A final cohort of 716 THA and 981 TKA procedures performed by22 surgeons was analyzed (Fig. 1). The mean years of clinical practice

on Implant Selection for Primary Total Hip and Knee Arthroplasty, J

Table 1Demographic Data for the THA and TKA Study Cohorts.

Variable

Academic Hospital Community Hospital P Value(Acadvs.

Comm)Pre-Capitated Post-Capitated P Value Overall Pre-Capitated Post-Capitated P Value Overall

Total hip arthroplastyNumber of cases; surgeons 215; 10 248; 10 463; 10 121; 7 132; 7 253; 7Age at surgery (yrs) a 61.9 (13.3)

[60.0–63.6]61.8 (13.2)[60.2–63.5]

0.97b 61.8 (13.2)[60.6–63.0]

67.3 (10.5)[65.4–69.2]

67.9 (10.2)[66.1–69.7]

0.64b 67.6 (10.3)[66.3–68.9]

b0.001b

Female c 124 (57.7%) 139 (56.0%) 0.72d 263 (56.8%) 72 (59.5%) 74 (56.0%) 0.58d 146 (57.7%) 0.82d

Body mass indexa 30.2 (6.5)[29.3–31.1]

29.9 (6.3)[29.2–30.7]

0.67b 30.1 (6.4)[29.5–30.6]

30.7 (8.3)[29.2–32.2]

30.8 (7.5)[29.5–32.1]

0.92b 30.8 (7.9)[29.8–31.7]

0.20b

Left laterality c 96 (44.6%) 128 (51.6%) 0.14d 224 (48.4%) 66 (54.5%) 61 (46.2%) 0.19d 127 (50.2%) 0.64d

Total kneearthroplastyNumber of cases 364; 12 302; 12 666; 12 155; 9 160; 9 315; 9Age at surgery (yrs) a 66.0 (10.2)

[64.9–67.0]65.6 (9.9)[64.5–66.7]

0.64b 65.8 (10.1)[65.1–66.6]

69.7 (10.4)[68.0–71.4]

66.7 (10.3)[65.1–68.3)

0.01b 68.2 (10.4)[67.0–69.3]

b0.001b

Female c 224 (61.5%) 169 (56.0%) 0.17d 393 (59.0%) 107 (69.0%) 98 (61.2%) 0.18d 205 (65.1%) 0.08d

Body mass indexa 31.8 (6.8)[31.1–32.5]

32.4 (6.9)[31.7–33.2]

0.26b 32.1 (6.8)[31.6–32.6]

32.7 (7.1)[31.6–33.8]

33.6 (6.8)[32.5–34.7]

0.26b 33.2 (7.0)[32.4–33.9]

0.03b

Left laterality c 177 (48.6%) 156 (51.7%) 0.48d 333 (50.0%) 82 (52.9%) 83 (51.9%) 0.94d 165 (52.4%) 0.53d

a Result values are expressed as mean (standard deviation) [95% confidence interval].b Welch's two-sample t-test.c Result values are expressed as number of cases (percentage).d Pearson's chi-squared test with Yates' continuity correction.

3M. Farías-Kovac et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

among academic and community hospital surgeons were 19.8 ±7.3 years (95% confidence interval, 15.2–24.5 years) and 23.3 ±7.9 years (95% confidence interval, 17.6–29.0 years), respectively(P = 0.30). The percentage of adult reconstruction fellowship-trainedsurgeons was 66.7% (n = 8/12) at the academic setting and 40.0%(n = 4/10) at the community hospitals (P = 0.21). The demographicmakeup of the THA and TKA study cohorts was similar across hospitaltypes, with only a slightly younger population being operated on atthe academic hospital for both procedures (P b 0.001) (Table 1).There were no significant differences in demographic data betweenprecapitation and postcapitation periods for each hospital type andprocedure (Table 1).

Implementation of a capitated pricing model at our institution hadno significant effect on the type of THA implant selected by eitheracademic center or community hospital surgeons (Table 2). At theacademic hospital, rates of premium THA implant usage slightlyincreased from 66.5% (n = 143) in the precapitation period to 70.6%(n = 175) in the postcapitation period, although this increase wasnot statistically significant (P = 0.28). Community hospital surgeonsselected considerably fewer premium implants (36.4%) in bothperiods compared to their academic hospital peers and did notchange their practice after the new pricing model was instituted(P = 0.95). Furthermore, therewere no cases of polyethylene 2G liner

Table 2Distribution of THA Implants by Premium Criteria Before and After Implementation of Capi

Variable

Academic Hos

Pre-Capitated(n = 215)

Post-Cap(n = 2

Premium 143 (66.5%) 175 (70.Polyethylene 2G liner—ceramic head 19 (8.8%) 17 (6.9Polyethylene 3G liner—ceramic head 101 (47.0%) 132 (53.Polyethylene 2G liner—oxidized-zirconium head 4 (1.9%) 11 (4.4Ceramic liner—ceramic head 17 (7.9%) 15 (6.0Mobile-bearing system 2 (0.9%) 0

Non-premiumPolyethylene 2G liner—metal head 28 (13.0%) 37 (14.Polyethylene 3G liner—metal head 44 (20.5%) 36 (14.

Result values are expressed as number of cases (raw percentage).a Logistic regression (GEE); adjusted for age, gender, and BMI.b Pearson's chi-squared test with Yates' continuity correction; corrected for multiple testc Fisher's exact test for count data; corrected for multiple testing.

Please cite this article as: Farías-Kovac M, et al, Effect of Price CapitationArthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.02.020

paired with oxidized-zirconium head, ceramic liner with ceramichead, or mobile-bearing systems (three of the five premium criteria)in either period at the community hospitals.

Premium TKA implant usage following implementation of the newpricing model significantly increased at the academic hospital from73.4% (n = 267) to 89.4% (n = 270) (P b 0.001) (Table 3). Mobile-bearing and high-flexion designs, which were not utilized in theprecapitation period, were used more frequently in the postcapitationperiod (1. 0%, P = 0.09; 5.3%, P b 0.001; respectively). Highly cross-linked polyethylene use at the academic hospital increased from73.4% (n = 267) to 83.1% (n = 251) (P = 0.005), and comprised themajority of this hospital type's premium implant usage. No TKA caseswith two or more premium criteria were used in either period byacademic center surgeons.

The community hospital surgeons selected premium TKA implantsat much greater rates than their academic peers (Table 3). In fact, allTKA cases at the community hospitals had at least one premiumcriterion, with no statistical significant changes in utilization of anysubgroup of implant. High-flexion knee system usage increased from10.3% (n = 16) to 18.8% (n = 30) (P = 0.11) following implemen-tation of price capitation. Mobile-bearing designs comprised a largeportion of the community hospitals' premium implant usage before(46.5%) and after (50.0%) capitated pricing (P = 0.57). There was a

tated Pricing, Classified by Hospital Type.

pital Community Hospital

itated48) P Value

Pre-Capitated(n = 121)

Post-Capitated(n = 132) P Value

6%) 0.28a 44 (36.4%) 48 (36.4%) 0.95a

%) N0.99b 2 (1.7%) 4 (3.0%) N0.99c

2%) N0.99b 42 (34.7%) 44 (33.3%) N0.99b

%) N0.99b 0 0%) N0.99b 0 0

N0.99c 0 0

9%) N0.99b 33 (27.3%) 37 (28.0%) N0.99b

5%) 0.82b 44 (36.4%) 47 (35.6%) N0.99b

ing.

on Implant Selection for Primary Total Hip and Knee Arthroplasty, J

Table 3Distribution of TKA Implants by Premium Criteria Before and After Implementation of Capitated Pricing, Classified by Hospital Type.

Variable

Academic Hospital Community Hospital

Pre-Capitated (n = 364) Post-Capitated (n = 302) P Value Pre-Capitated (n = 155) Post-Capitated (n = 160) P Value

Premium (≥1 below criteria) 267 (73.4%) 270 (89.4%) b0.001a 155 (100.0%) 160 (100.0%)Mobile-bearing design 0 3 (1.0%) 0.09b 72 (46.5%) 80 (50.0%) 0.57b

High-flexion design 0 16 (5.3%) b0.001b 16 (10.3%) 30 (18.8%) 0.11b

Oxidized-zirconium femoral component 0 0 0 0Highly cross-linked polyethylene 267 (73.4%) 251 (83.1%) 0.005b 70 (45.2%) 53 (33.1%) 0.11b

Result values are expressed as number of cases (raw percentage).a Logistic regression (GEE); adjusted for age, gender, and BMI.b Fisher's exact test for count data; multiplicity corrected.

4 M. Farías-Kovac et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx

decrease in the use of highly cross-linked polyethylene from 45.2%(n = 70) to 33.1% (n = 53) (P = 0.11). No oxidized-zirconiumfemoral components were used in either time period or at eitherhospital type. The majority of the community hospital TKA cases hadonly one premium criterion, with three cases before and aftercapitated pricing having two premium criteria.

Discussion

As of 2010, Medicare, Medicaid, and private insurers were themajor sources of reimbursement for THA and TKA in the United States,representing 53%, 14%, and 31% of these cases, respectively [3].Accordingly, 67% of THA and TKA reimbursement nationally aresubjected to diagnosis-related group (DRG) weights and payments bythe Centers for Medicare & Medicaid Services. A recent studyexamining amounts paid to manufacturers by 61 institutions across8 different states in 2008 showed an average total surgical cost for THAand TKA of $12,548 and $11,666, respectively, with implant costaccounting for 50.2% and 43.5% of the surgical cost, respectively. Amultivariate regression analysis of these data for both proceduresfound higher implant costs were associated with age, payer (Medi-care), complications, discharge disposition (discharge to acute or post-acute care facility), and a diagnosis of fracture (for TKA only) [20].

Prior to establishing a capitated pricing model for primary totaljoint implants, our institution utilized a two-vendor buying systembased on volume discounts. This previous approach required anintegrated physician organization and limited the number of implantvendors, theoretically reducing the competition to stimulate in-creased willingness to discount prices [21]. Under this model thephysician's choice of orthopedic implants for THA and TKAwas largelyrestricted to those offered by two medical device companies in orderto assure high demand by the hospitals in our health system. This highvolume was matched with discounted prices by the vendors. Ourinstitution ultimately migrated away from this pricing model insearch of higher surgeon satisfaction and patient outcomes through awider range of implant options while maintaining acceptable costs.Implementation of a capitated pricing model helped remove ourinstitution's reliance on discount- and volume-based purchasing aswell as cut total implant costs by approximately 10% overall for THAand TKA, while increasing the range of manufacturers and on-the-shelf implant options available to surgeons. It is also important to notethat the term premium implants may be misleading. We use this termto define implants that were marketed as premium implants and hadlist pricing commensurate with their perceived premium status.

To our knowledge, there is only one other detailed report in theliterature of a capitated pricing system used for orthopedic implantpurchasing. Taylor et al [13] presented similar positive financialresults at their institution after implementation of a four-tier pricecapitation system for purchasing THA and TKA implants, reducingcosts per implant by 26.1%. This tiered categorization matrix placedimplants with similar levels of technology or innovation in categories(I-IV) based on implant fit and bearing surface, and negotiated a pricefor each category. The classification implemented in our study was a

Please cite this article as: Farías-Kovac M, et al, Effect of Price CapitationArthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.02.020

modified version of that used by Gioe et al [1], focusing on bearingsurface technology and classifying implants as premium or non-premium (e.g. 2 categories). Taylor et al [13] found no statisticallysignificant change in overall implant selection at their institution.However, usage of their most premium and expensive THA and TKAimplants (category IV) increased from 55.8% to 63.4% and 26.8% to29.0%, respectively, with implementation of the new system. Atheoretical disadvantage of tiered capitated pricing systems is thatcost is not removed entirely from the implant selection equation as aprice difference between premium and non-premium implants isretained. No studies to date have reported the effect of a single pricecap system, like the one used at our institution, on implant selection.

There are noted obstacles that can be encountered when trying toestablish a price capitation system. In particular, capitated pricingmodels typically require large volumes to negotiate beneficial pricinganddependingonbuyingpower, theymight not cover thepurchasingofcertain goods (e.g., newest technology), which would require separatepricing contracts or purchasing at themanufacturer's list price. Also, thespecifics of a capitated pricingmodel can vary greatly depending on thenecessities or goals of the buyer and the demands of the seller.

There are substantial differences in practice patterns betweenacademic and community hospitals for both THA and TKA. The datafrom our institution demonstrate that the influence of capitatedpricing is very different for hip and knee implants, with a trendtoward increased premium implant usage for primary TKA in theacademic setting only. No statistically significant changes in premiumimplant selection were found for primary THA in either location.Additionally, private practice community hospital surgeons usedpremium TKA implants at very high rates (100.0%) and premium THAimplants at very low rates (36.4%). We believe that these differencesin implant selection between procedure typemay be due to the higherlevels of satisfaction among patients after THA compared to TKA [22–24].Surgeonsmaypursuenovel andpremiumtechnologies at greater rates forTKA in search of better outcomes for these patients.

As hypothesized, the private practice community hospitals appearto be less affected than the academic center in premium THA and TKAimplant usage following implementation of price capitation. In fact,while some individual premium criterion rates increased or decreasedbetween time periods, neither THA nor TKA overall premium implantusage statistically changed at the community hospitals. However theceiling effect observed in TKA at the community hospitals with 100%overall premium criteria implant use for both periods makescomparison between practices difficult. Nonetheless, TKA premiumcriterion subgroups were not affected by this ceiling effect and stillhad no statically significant changes. Observed variation in implantselection between hospital settings may highlight the dichotomy inreimbursement systems.

The present study had several notable limitations. First, theretrospective design did not allow for control of potential confound-ing variables between precapitation and postcapitation periods, suchas differences in patient populations and surgeons. However, the basicdemographics were similar across time periods and exclusion criteriawere established to minimize variables that could influence implant

on Implant Selection for Primary Total Hip and Knee Arthroplasty, J

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selection. Second, the new capitated pricing policy was accompaniedby the addition of five new manufacturers to the previous list ofpreferred vendors, expanding to a 7-vendor system. We believe thatthis concurrent change had little effect on implant selection. Of the 22surgeons who performed surgeries in both periods, only 1 surgeonswitched to a different implant manufacturer in the postcapitationperiod and all manufacturers offered at least one premium system.Third, although no implants were retired from the market during thestudied periods, two implants were voluntarily recalled by themanufacturers within months of the end of the postcapitation period.The knowledge of the issues that prompted these recalls could haveaffected its use by surgeons in both academic and communityhospitals prior to its recall. Fourth, the length of the study waslimited to 6 months before and after implementation of pricecapitation. This represents a snapshot in time, and implant selectionpractice patterns could change.

The results of this study represent a first effort at examining theimpact of price capitation on premium implant selection at academicand community hospital settings. Further reporting of the financialimplications and implant usage trends of different capitated pricingsystems is necessary to clarify if price capitation can help sustainimplant cost reductions and what institutions might benefit mostfrom this type of pricing model.

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