The impact of political partisanship, certificate of need, Medicaid expansion, and area deprivation index on total shoulder arthroplasty prices in the United States

Abstract

Recent mandates from the Center for Medicare and Medicaid Services (CMS) require United States hospitals to disclose healthcare service pricing. Yet, there's a gap in understanding how state-level factors affect hospital service pricing, like total shoulder arthroplasty (TSA). Comprehending these influences can help policymakers and healthcare providers manage costs and improve care access for vulnerable populations. The purpose of this study was to examine the effect of state characteristics such as partisan lean, Certificate of Need (CON) status, and Medicaid expansion, on TSA price. TSA price data was extracted from the Turquoise Health Database using CPT code 23472. State partisan lean was determined by evaluating each state during the 2020 election year for its legislature (both senate and house), governor, presidential vote, and Insurance Commissioner affiliation, categorizing states as either "Republican-leaning" or "Democratic-leaning." CON status, Medicaid expansion, area deprivation index (ADI), and population density information was obtained from publicly available sources. Multivariable regression models were used to assess the relationship between these factors and TSA price. The study included 2,068 hospitals nationwide. The median (IQR) price of TSA across these hospitals was $12,607 ($9,185). In the multivariable analysis, hospitals in Republican-leaning states were associated with a significantly greater price of +$210 (p = 0.0151), while Medicaid expansion was also associated with greater price +$1,878 (p < 0.0001). CON status was associated with a significant reduction in TSA prices of -$2,880 (p < 0.0001). In North Carolina an ADI >85 was associated with a reduction in price (p = 0.0045), while urbanization designation did not significantly impact TSA price (p = 0.8457). This cross-sectional observational study found that Republican-leaning states and Medicaid expansion were associated with increased TSA prices, while an ADI >85 and CON laws were associated with reduced TSA prices.