Should Total Joint Arthroplasty (TJA) be Funded by CMS?

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Current data suggests that over 750,000 total joint arthroplasties (TJA)  or joint replacements will be performed every year, making this procedure one of the most widely performed interventions in the US with positive long term effects on pain, mobility, and function. Over one half of all TJAs performed in the US are paid for by Centers for Medicare & Medicaid Services (CMS), which makes their decision to pay or decline payment extremely important in deciding who gets their function back and under what circumstances.

Due to the high cost of these procedures and the effort to contain the cost of health care within the US, CMS has long been looking to TJAs as a source of possible savings if the procedure could be rationed based on predetermined set of criteria. In spite of the fact that demand for TJAs is projected to rise dramatically over the next thirty years, Medicare reimbursements are slated to be cut a total of 40% from 2001 levels by the year 2016. This would actually have a detrimental effect on our nation’s health and its healthcare budget, as can be seen in the case of Medicaid/Medicare enrollees who are chronically dependent on non-steroidal anti-inflammatory medications (NSAIDS) for joint pain relief.

It has been shown in several studies that patients who forego TJA and become dependent on these drugs actually end up incurring more detrimental health effects and thus health expenditures rise above the level expected if joint replacement had been done. Not to mention, when citizens become immobilized by joint pain, they generally are disabled and can no longer function as fully employed members of society. They are then predisposed to further risk factors for poor health such as obesity, substance abuse, and cardiovascular disease. Thus, TJA is an investment which though somewhat expensive, provides near immediate return of function to most patients and prevents further insults to health which may interfere with a citizen’s ability to live a productive life. Please support continued medicare/medicaid funding of total joint arthroplasty in any way possible, including the following:

1. Stay informed by visiting aaos.org, healthpayernews.org, or healio.com/orthopedics,  where the latest updates on reimbursement for TJA can be found

2. Contribute to AAOS’ political action committee at aaos.org/pac

3. Correspond with your congressional representatives and let them know your thoughts on medicare reimbursement. http://www.capwiz.com/ama/issues/alert/?alertid=53132696

4. Visit the American Medical Associations’s Patient Action Network: http://www.patientsactionnetwork.org

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2 Responses to “Should Total Joint Arthroplasty (TJA) be Funded by CMS?”

  1. golnazheidari Says:

    This is a very important issue. I support the medicare/medicaid funding of total joint arthroplasty. However, one of the major concerns about this issue is that medicare/medicaid funding of TJAs can lead to overutilization of the service and increase the unnecessary cases of TJAs. It is very important that medicare/medicaid find a way to control these unnecessary cases.

  2. vgundareddy Says:

    As a physician here are my 2 cents. I agree that TJAs are on a rise and will go up dramatically as the baby boomers are coming of age to get their TJAs done. Another reason for increased TJAs is the obesity epidemic and the core question is how do we reduce the need for TJAs rather than who should pay for it. CMS should by all means pay for this procedure if it is needed medically. At present there are a set of rules that determine that patient has tried and failed all other modalities of treatment prior to getting TJAs. Given the high denial rates from CMS of elective TJAs all hospitals have a utilization review in place that screens a CMS patient prior to surgery and then a green light is given if the patient has tried and failed all outpatient treatments and meets CMS criteria to get TJAs. If they do not meet the criteria patient will have to pay out of pocket to get the surgery. This has decreased the denial rates of TJAs however question again is policies directed at reducing incidence of Osteoarthritis would better serve public health than policies to deter patients from getting TJAs when needed.

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