Dr. Anthony Sapienza comments on the article, Huetteman HE, Zhong L, Chung KC. Cost of surgical treatment for distal radius fractures and the implications of episode-based bundled payments. J Hand Surg Am. 2018;43(8):720-730.
Huetteman et al examined a national dataset to understand the cost of care for surgical treatment of a distal radius fracture (DRF), with the goal of developing episode-of-care scenarios that could be used as the basis for DRF bundled payment models.
To compile the cost information, they looked at insurance claims from the 2009 to 2015 MarketScan Commercial Claims data set (more than 43 million individuals across the US) and the Encounters Database and Medicare Supplements. These data facilitate longitudinal tracking of enrollees over time. They also permit researchers to capture complete episodes of care through the compilation of claims from office visits, hospital stays, prescriptions, and laboratory tests.
Huetteman et al included patients who:
- Had an ICD-9 code indicating a primary diagnosis of DRF
- Underwent surgical fixation (open reduction internal fixation [ORIF], percutaneous pinning, or external fixation) within 2 weeks of the fracture
- Had continuous enrollment in the datasets for 12 months prior to the index surgery date to assess for comorbidities
- Maintained continuous enrollment for 6 months after the surgery date
Their exclusion criteria were:
- Concomitant hip, pelvis, spinal, femoral, patella, tibial, or ankle fracture
- Major orthopedic surgery (total hip arthroplasty, total knee arthroplasty, or hip fracture surgery) within 6 months of DRF
- Diagnosis of kidney failure, end-stage renal disease, breast cancer, or pregnancy
- Nursing home resident
The authors evaluated 4 scenarios to define the episode of care, which included the 3 days prior to the index surgery date and:
- 30-day comprehensive
- 90-day comprehensive
- 30-day DRF-related
- 90-day DRF-related
The following chart details the costs they calculated for each of the 4 episode-of-care scenarios:
Huetteman et al showed that the cost of caring for a patient with DRF is variable, with many cases costing more than 3 standard deviations over the national average. Depending on the model used to define an episode of care, this average variation ranged from $4548 to $5261.
These findings highlight the need to standardize care of DRF patients to reduce these discrepancies in costs. Clinical judgment for the treatment type and patient preference should not be superseded by the factor of cost alone but should weigh heavily in the decision tree as we shift to a climate of value-based medicine. For example, the value of an earlier return to work and activities of daily living may outweigh the additional costs associated with ORIF over a percutaneous pinning surgical technique.
Although slight variation in treatment type and associated cost is inevitable, elimination of even the costliest outliers through initiatives like payment bundling could substantially decrease variation and lessen the burden of DRF treatment costs on the health system. The authors postulate that a bundled payment initiative will have considerable effect on the current reimbursement patterns in play for DRF operations, ultimately reducing costs to payers.
At the time this article was written, Anthony Sapienza, MD, was an Assistant Professor of Orthopaedic Surgery at NYU Langone Orthopedic Hospital, New York, New York. He is now with NY Orthopedics in New York, New York.
Dr. Sapienza has no disclosures relevant to this article.
This article was originally published as What Is the Episode-of-Care Cost for a Distal Radius Fracture? in the NYU Langone Orthopedics Journal Watch section of www.ICJR.net. Republished with permission.