Variables Affecting 90-Day Overall Reimbursement After Anterior Cruciate Ligament Reconstruction: Analysis of Nearly 250,000 Patients in the United States

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. As the number of ACLRs continues to increase in incidence, understanding the variability and drivers of cost to the health care system may help target cost-saving measures.

Purposes: To examine the variability in overall 90-day reimbursements (amount paid for health care services) for ACLR using a national, multi-insurance, administrative database and to assess factors associated with variability.

Study design: Cross-sectional study.

Methods: Using the M151 PearlDiver data set (data from 2010 to April 30, 2021), the authors identified the 90-day total reimbursements in patients who underwent ACLR. Patient age, sex, and comorbidity burden; insurance type; inpatient versus outpatient surgery status; and 90-day postoperative adverse events were determined and were correlated with overall reimbursements using multivariable logistic regression.

Results: A total of 249,484 patients who underwent ACLR during the study period were identified. The mean patient age was 31.6 ± 13.58 years, 50.3% were female, the mean Elixhauser Comorbidity Index (ECI) was 1.4 ± 1.8, and procedures were performed on an outpatient basis for 245,507 patients (98.4%). Insurance type was commercial for 220,284 patients (88.3%), Medicaid for 17,660 (7.1%), and Medicare for 3500 (1.4%). The mean overall 90-day reimbursement was $4281.91 ± $4982.61 (median [interquartile range], $3032 [$1681-5142]), and the total reimbursement for the patient cohort was $1,049,250,747. On multivariable linear regression, the variables independently associated with the greatest changes in overall reimbursement were (in decreasing order) hospital readmission (+$17,675.23), adverse events (+$1554.14), inpatient procedure (+$1246.51), and emergency department visits (+$784.06). Lesser but significant associations were found with greater ECI (+$252.30) and female sex (+$101.01). Decreased overall reimbursement was associated with older age (-$12.19) and Medicare (-$883.48)/Medicaid (-$493.18) relative to commercial insurance.

Conclusion: In the current study, large variability was found in overall ACLR reimbursement/cost within the health care system. Hospital admissions (inpatient surgery and readmission) and adverse events were associated with the greatest increase in costs and emphasize the need to optimize these metrics above and beyond patient experience.

Keywords: PearlDiver; anterior cruciate ligament; health care cost; knee; ligaments; reimbursement.

Figure 1.

Graph showing the incremental payment differences seen in Table 2. All variables are statistically significant (P < .0001). ECI, Elixhauser Comorbidity Index; ED, emergency department.