Higher Patient Complexity Generates Greater Hospital Revenue Without Proportional Surgeon Compensation in Revision Total Joint Arthroplasty.

BACKGROUND: Revision total joint arthroplasty (TJA) is generally performed in older and more medically complex patients, imposing a categorically greater clinical burden on both hospitals and surgeons. Prior research has established that surgeons caring for more medically complex patients undergoing primary TJA receive disparate financial incentives compared with hospitals. Whether this structural disparity extends to the revision TJA setting remains unstudied. We hypothesized that hospitals receive relatively higher reimbursements for higher-risk patients, while surgeons do not receive proportionally increased reimbursements.

METHODS: Public Medicare datasets were queried to identify surgeon Current Procedural Terminology (CPT) observations for aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), and hospital diagnosis-related group (DRG) observations for inpatient revision THA and TKA. Observations were stratified into high-risk (Hierarchical Condition Category [HCC] ≥ 1.5) and standard-risk (HCC less than 1.5) cohorts based on the mean HCC risk score of each surgeon's or hospital's Medicare panel. Group comparisons were performed using independent-samples t-tests, and univariable linear regression was used to examine associations between HCC risk score, comorbidity prevalence, and mean reimbursement within each cohort.

RESULTS: In 2023, 8,718 revision TJA procedures were represented by 526 surgeon-CPT observations, and 25,188 inpatient revision TJA discharges were represented by 1,083 hospital-DRG observations. Mean hospital reimbursement was significantly greater in the high-risk cohort than in the standard-risk cohort ($24,574.9 ± 11,074.9 versus $20,080.8 ± 6,722.8; P < 0.001). Mean surgeon reimbursement did not differ significantly between cohorts ($1,132.3 ± 504.5 versus $1,024.0 ± 522.8; P = 0.152). Within the high-risk cohort, higher HCC score was associated with lower surgeon reimbursement (β = -1,155; 95% confidence interval: -1,642 to -668; P < 0.001). The hospital-to-surgeon reimbursement ratio was 19.6× in the standard-risk cohort and 21.7× in the high-risk cohort.

CONCLUSION: Hospital reimbursement for revision TJA scaled significantly with increased patient comorbidities while surgeon reimbursement remained unchanged. This widening hospital-to-surgeon reimbursement ratio demonstrates a meaningful mismatch in how Medicare compensates surgeons for complexity, which should inform policy efforts to promote risk-adjusted surgeon reimbursement and preserve access to revision arthroplasty for the highest-risk patients.