Insurance Payer Type Affects Outcomes after Revision Total Joint Arthroplasty: A Matched Cohort Analysis

Document Type : RESEARCH PAPER


Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA


Background: The aim of this study is to evaluate the potential effects of insurance payer type on the postoperative 
outcomes following revision TJA. 
Methods: A single-institution database was utilized to identify 4,302 consecutive revision THA and TKA. Patient 
demographics and indications for revision were collected and compared based on patient insurance payer type: (1) 
Medicaid, (2) Medicare, and (3) private. Propensity score matching and, subsequent, multivariate regression analyses 
were applied to control for baseline differences between payer groups. Outcomes of interest were rates of complications 
occurring perioperatively and 90 days post-discharge.
Results: After propensity-score-based matching, a total of 2,328 patients remained for further multivariate regression 
analyses (300 [12.9%] Medicaid, 1022 [43.9%] Medicare, 1006 [43.2%] private). Compared to privately insured patients, 
Medicaid and Medicare patients had 71% (P<0.01) and 53% (P=0.03) increased odds, respectively, for developing an 
in-hospital complication. At 90 days post-discharge, compared to privately insured patients, Medicaid and Medicare 
patients had 88% and 43% odds, respectively, for developing overall major complications.
Conclusion: Our propensity-score-matched cohort study found that, compared to privately insured patients, patients 
with government-sponsored insurance were at an increased risk for developing both major or minor complications 
perioperatively and at 90-days post-discharge for revision TJA. This suggests that insurance payer type is an 
independent risk factor for poor outcomes following revision TJA.
Level of evidence: III


  1. Bozic KJ, Lau E, Kurtz S, Ong K, Rubash H, Vail T, et 
    al. Patient-related risk factors for periprosthetic joint 
    infection and postoperative mortality following total 
    hip arthroplasty in Medicare patients. J Bone Joint 
    Surg Am. 2012;94(9):794-800. 
    2. Feng JE, Gabor JA, Anoushiravani AA, Long W, 
    Vigdorchik J, Macaulay W. Payer type does not impact 
    patient-reported outcomes after primary total knee 
    arthroplasty. Arthroplast Today. 2019;5(1):113-118. 
    3. Deber R, Gamble B. What’s in, what’s out: stakeholders’ 
    views about the boundaries of Medicare. Health Q. 
    4. Veltre DR, Sing DC, Yi PH, Endo A, Curry E, Smilth EL, 
    et al. Insurance status affects complication rates after 
    total hip arthroplasty. J Am Acad Orthop Surg. 2019; 
    5. Browne JA, Novicoff WM, D’Apuzzo MR. Medicaid 
    payer status is associated with in-hospital morbidity 
    and resource utilization following primary 
    total joint arthroplasty. J Bone Jt Surg - Am Vol. 
    6. Hayes S, Napolitano MA, Lent MR, Wood GC, Gerhard 
    GS, Irving BA, et al. The Effect of Insurance Status on 
    Pre- and Post-operative Bariatric Surgery Outcomes. 
    Obes Surg. 2015;25(1):191-194. 
    7. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections 
    of primary and revision hip and knee arthroplasty in 
    the United States from 2005 to 2030. J Bone Joint Surg 
    Am. 2007;89(4):780-785. 
    8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A 
    new method of classifying prognostic comorbidity in 
    longitudinal studies: Development and validation. J 
    Chronic Dis. 1987;40(5):373-383. 
    9. McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, 
    Ramchand R, Burgette LF. A tutorial on propensity score 
    estimation for multiple treatments using generalized 
    boosted models. Stat Med. 2013;32(19):3388-3414. 
    10.Feng B, Xiao K, Gao P, Liu Y, Zhang B, Ren Y, et al. 
    Comparison of 90-Day Complication Rates and Cost 
    Between Single and Multiple Joint Procedures for 
    End-Stage Arthropathy in Patients with Hemophilia. 
    JB JS open access. 2018;3(4):26-31. 
    11.Huang KT, Hazzard MA, Babu R, Ugilweneza B, 
    Grossi PM, Huh BK, et al. Insurance disparities in 
    the outcomes of spinal cord stimulation surgery. 
    Neuromodulation. 2013;16(5):428-434.
    12.Halawi MJ, Stone AD, Gronbeck C, Savoy L, Cote MP. 
    Medicare coverage is an independent predictor of 
    prolonged hospitalization after primary total joint 
    arthroplasty. Arthroplast Today. 2019;5(4):489-492. 
    13.Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley 
    MT. Which Clinical and Patient Factors Influence the 
    National Economic Burden of Hospital Readmissions 
    After Total Joint Arthroplasty? Clin Orthop Relat Res. 
    14.Kamath AF, Ong KL, Lau E, Chan V, Vail TP, Rubash 
    H, et al. Quantifying the Burden of Revision Total 
    Joint Arthroplasty for Periprosthetic Infection. J 
    Arthroplasty. 2015;30(9):1492-1497. 
    15.Maman SR, Andreae MH, Gaber-Baylis LK, Turnbull 
    ZA, White RS. Medicaid insurance status predicts 
    postoperative mortality after total knee arthroplasty 
    in state inpatient databases. J Comp Eff Res. 
    16.Saleh A, Small T, Pillai ALPC, Schiltz NK, Klika AK, 
    Barsoum WK. Allogenic blood transfusion following 
    total hip arthroplasty: Results from the nationwide 
    inpatient sample, 2000 to 2009. J Bone Jt Surg - Am 
    Vol. 2014;96(18):155-161. 
    17.McMorrow S, Long SK, Fogel A. Primary care providers 
    ordered fewer preventive services for women with 
    medicaid than for women with private coverage. 
    Health Aff. 2015;34(6):1001-1009. 
    18.Saloner B. Medicaid Expansion, Chronic Disease, and 
    the Next Chapter of Health Reform. J Gen Intern Med. 
    19.Shau D, Shenvi N, Easley K, Smith M, Bradbury T, Guild 
    G. Medicaid payer status is associated with increased 
    90-day morbidity and resource utilization following 
    primary total hip arthroplasty: A propensityscore-matched analysis. J Bone Jt Surg - Am Vol.