Unintended Consequences? Medicare Commercial Partnerships Complicate Arthroplasty Care and Registry-Based Research: Commentary on an article by Jennifer C. Wang, BS, et al.: "The Rise of Medicare Advantage. Effects on Total Joint Arthroplasty Patient Care and Research".

Abstract

Commentary The health-care environment has undergone major changes over the past 20 years, including the expansion of partnerships between commercial insurance carriers and the U.S. Department of Health and Human Services (HHS) through its subagency, the Centers for Medicare & Medicaid Services (CMS). Most orthopaedic surgeons performing arthroplasty procedures have probably observed the growing proportion of their patients with Medicare Advantage (commercially managed Medicare) plans. Few among us were likely aware of the full implication of this transition on clinical practice, patient outcomes, and the effectiveness of registry-based arthroplasty research. Wang and colleagues provide a thoughtful analysis of patient demographic characteristics, medical comorbidities, and 90-day postoperative adverse outcomes that were identified for 697,317 patients who underwent elective total hip or total knee arthroplasty in hospitals participating in the Premier Healthcare Database. The authors identified a 335% relative increase in patient participation in Medicare Advantage plans from 2004 to 2020, with increased enrollment of non-White patients, a propensity for increased Medicare Advantage enrollment in urban environments, and increased arthroplasty care engagement in teaching hospitals. While differences in medical comorbidities were not substantially different between patients enrolled in the 2 plan types, Medicare Advantage patients experienced an increased risk for stroke and acute kidney injury following surgery. The authors extrapolate their findings beyond the core data obtained to present their perspectives on the impact of CMS insurance privatization on the future of high-quality joint arthroplasty care. Increased administrative burdens, including pre-authorization coordination for appropriate and clinically indicated surgical treatment, have been encountered by most practicing surgeons and their support teams. The transition of quality reporting through qualified registries—including the American Joint Replacement Registry—has been built around traditional Medicare enrollment reporting mechanisms. At least 1 potentially unintended consequence of the transition toward Medicare Advantage plans is the shielding of patient-based procedural outcomes from these mechanisms—which may serve to undermine innovation and validation. There are some notable limitations of the study, which the authors have outlined. It is very challenging to use administrative databases to fully identify and investigate all factors that may influence adverse postoperative outcomes. While the database used by the authors identifies postoperative surgical and medical complications, it does not address the long-term performance of the implants and techniques. Moreover, the composite medical complexity of patients may not be fully represented in the analyzed data. The factors and conditions underlying patient decisions to select traditional Medicare or Medicare Advantage plans cannot be assessed, and the potential impact of selection bias on the study findings cannot be determined. The study highlights the unanticipated consequences that may arise when fiscally driven policy intersects with specialized medical care. Future studies will be valuable to determine whether the observations in this study are sustained as the growth of Medicare Advantage plans continues—especially with the trends suggesting that under-represented minority patients will potentially be the most adversely affected. With potential implications for arthroplasty care delivery and the future ability to utilize qualified registries to assess arthroplasty outcomes, it is crucial for advocacy efforts to guide policymakers toward ensuring the successful provision of arthroplasty care—including transparency of outcomes among patients who have elected to participate in Medicare Advantage programs.