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follow-up during the first 3 months after surgery? ◾ How much do you think the implant used in your surgery cost? ◾ How much do you think the hospital was reimbursed for your surgery and admission to the hospital after surgery? (EXCLUDING payments to the surgeon) ◾ How much do you think it cost the hospital to provide your surgery and admission to the hospital after surgery? Responses were limited to numeric currency format using a response area as shown in Figure 1. Overall patient satisfaction was elicited with use of a 5-point scale ranging from 1 (very unsatisfied) to 5 (very satisfied). Regarding type of implant used, patients could select from 6 prominent vendors or indicate “other” or “don’t know.” They were also asked which of several factors should primarily determine surgeon reimbursement: overall patient satisfaction, technical difficulty, amount of risk/possible harm, duration/amount of time, and rate of complications. A free-response comments section was provided at the end of the survey. Data from the survey and the electronic medical records were collected using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, Tennessee). Statistical analysis was performed with SAS Version 9.3 (SAS Institute, Cary, North Carolina). Data were screened before further analysis. Patients who provided nonnumeric responses in numeric response fields were excluded from further analysis. Numeric ranges were applied in subsequent analysis using the mean of the range. Implausible responses resulted in the removal of the entire encounter from subsequent analysis. Demographic data used to define categories for further subgroup analysis are presented as percentages of the group. Medians, means, and interquartile ranges were calculated for all responses regarding reimbursement and cost. Differences in perceptions of reimbursement and cost based on subgroups, including procedure type, diagnosis, education level, and satisfaction, were calculated. Independent-samples Student t tests were used to determine the statistical significance of the differences detected. Results Of the 400 eligible patients seen at the first postoperative follow-up, 284 (71%) were enrolled in the study. Mean (SD) age was 62.6 (12.6) years. Of the 284 patients enrolled, 154 (54%) were female. Of the participants who reported their education and income, 125 (44%) had a bachelor’s degree or higher degree, and 68 (23.9%) reported income of more than $100,000 per year. The largest payers reported by patients were private insurance (80%) and Medicare (46%). Additional demographic details are listed in Table 1. Of the 284 patients enrolled in the study, 159 (56%) had THA, and 88 (31%) had TKA (Table 2). Thirty-seven patients (13%) underwent revision procedures. Only 5 patients (2%) indicated they had reviewed their hospital billing statement from Figure 1. Response area for estimated cost or payment was limited to numeric currency format. Table 1. Study Participants’ Demographic Data Highest Education Level Attained n % Some high school 14 5 High school graduate 52 18 Some college 66 23 Associate’s degree 23 8 Bachelor’s degree 61 21 Master’s degree 37 13 Professional degree 7 2 Doctoral degree 20 7 No response 4 1 Annual Household Income n % $150,000 32 11 No response 15 5 Payer Identified by Participant n % Private insurance 227 80 Self-pay/uninsured 1 0.4 Medicare 132 46 Medicaid 20 7 Other 25 9 Unsure 1 0.4 J. D. Maratt et al www.amjorthopedics.com May 2015 The American Journal of Orthopedics® E137 their most recent admission. Two hundred forty-two patients (85%) were satisfied or very satisfied with their procedure. Regarding the implant used in their surgery, 216 patients (76%) indicated they did not know which company manufactured it. Of the 68 patients (24%) who named a manufacturer, 53 (78%) were correct in their selection (intraoperative records were checked). Patients indicated they thought the implant used in their surgery cost $6447 on average (95% CI, $5581-$7312). On average, patients thought their surgeon was reimbursed $12,014 (95% CI, $10,845-$13,183) for their procedure, and they estimated that the hospital was reimbursed $28,392 (95% CI, $25,271-$31,512) for their perioperative care and that it cost the hospital $24,389 (95% CI, $21,612-$27,165) to provide it. Means, confidence intervals, medians, and interquartile ranges for parameters of reimbursement and cost are listed in Table 3. Seventy-one patients (25%) thought on average that the hospital took a net loss for each TJA performed, and 146 patients (51%) thought on average that the hospital generated a net profit for each TJA. On average, patients thought surgeons were reimbursed $11,872 for a THA and $12,263 for a TKA. Patients also estimated a higher hospital cost (THA, $22,981; TKA, $26,998) and reimbursement (THA, $27,366; TKA, $30,230) after TKA than THA. These differences in perceptions of cost and reimbursement for THA and TKA appear in Table 4 and Figure 2. Statistically significant differences were also found in perceptions of cost and reimbursement based on level of education and overall patient satisfaction. Patients with a bachelor’s degree or higher estimated physician reimbursement at $11,006, whereas patients with a lower level of education estimated
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