The Economics of Anterior Cruciate Ligament Reconstruction

Published on 11/04/2015 by admin

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Chapter 9 The Economics of Anterior Cruciate Ligament Reconstruction

Institutional Fixed Costs

These costs are a combination of time charges, which reflect fixed costs of operation such as rent, utilities, and staffing, and additional costs associated with the given procedure.1,2 In 1996, Novak et al2 published rates of $12,040 for hospital ACLR with admission, $8815 for hospital ACLR with same-day discharge, and $3853 for surgicenter ACLR. A representative survey of Chicago-area hospitals and surgicenters indicates that current total charges typically vary from $5000 to $12,000 for ACLR. In the following discussion, we will break down the component costs that are additive to the basic institutional time costs.

Anterior Cruciate Ligament Reconstruction–Specific Additive Costs

Allografts

Allografts are increasing rapidly in popularity. A survey of the largest U.S. tissue banks discloses a price range for various ACL allografts of $1400 to more than $3000, with a mean of about $2000 per case. A recently published study3 using patient data from 1996 to 1998 showed allografts at that time to substantially reduce costs by decreasing the likelihood of admission and decreasing surgical time. However, today virtually all ACLR procedures may be performed as outpatient with the use of femoral blocks (see later), so there is little further potential cost savings in this regard from the use of allografts. Even without the use of femoral blocks, ACLR can usually be performed easily on an outpatient basis.

Allograft use will produce slightly decreased costs from reduced operating time due to the absence of a surgical harvest. Experienced surgeons will generally accomplish the harvest in about 10 minutes, but the time may be substantially higher for surgeons who perform the procedure only occasionally. In either case the reduced time will not significantly offset the high cost of the allograft; in addition, there is some diversion of assistant or surgeon time involved in opening, thawing, and washing the allograft. The other potential benefit of allograft use is avoidance of harvest morbidity. This may be significant regarding kneeling pain after bone–patellar tendon–bone (BPTB) harvest. The morbidity for hamstring harvest has been shown to be negligible. Disadvantages with allograft versus autograft use may include lower stability rates4 (see Chapter 69) as well as the small but definite risk of disease transmission.

The cost implications of widespread allograft use are staggering. Macroeconomically, $2000 per allograft multiplied by an estimated 110,000 predicted ACLRs yields a cost differential of more than $200 million between no use of allografts and complete use of allografts nationwide. Microeconomically, if allografts are not separately reimbursed above the basic cost of the procedure, their use will virtually always cause the procedure to be performed at a net loss to the institution. Because most contracts do reimburse for allografts, this is often not an issue, but it is important to be aware of contract provisions at the given institution for the specific payer involved.