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To determine whether needle arthroscopy (NA) compared with magnetic resonance imaging (MRI) in the diagnosis and treatment of meniscal tears is cost-effective when evaluated over a 2-year period via patient-reported outcomes. The hypothesis is that improved diagnostic accuracy with NA would lead to less costly care and similar outcomes.
Methods
A Markov model/decision tree analysis was performed using TreeAge Pro 2017 software. Patients were evaluated for degenerative and traumatic damage to the lateral/medial meniscus. Assumed sensitivities and specificities were derived from the medical literature. The direct costs for care were derived from the 2017 Medicare fee schedule and from private payer reimbursement rates. Costs for care included procedures performed for false-positive findings and for care for false-negative findings. Effectiveness was examined using the global knee injury and osteoarthritis outcome score (KOOS). Patients were evaluated over 2 years for costs and outcomes, including complications. Dominance and incremental cost-effectiveness were evaluated, and 1- to 2-way sensitivity analysis was performed to determine those variables that had the greatest effect. The consolidated economics evaluation and reporting standards checklist for reporting economic evaluations was used.
Results
NA was less costly and had similar KOOS versus MRI for both the medial/lateral meniscus with private pay. Costs were less for both Medicare and private pay for medial meniscus, $780 to $1,862, and lateral meniscus, $314 to $1,256, respectively.
Conclusions
Based on the reported MRI incidence of false positives with the medial meniscus and false negatives with the lateral meniscus and based on assumed standards of care, more costly care is provided when using MRI compared with NA. Outcomes were similar with NA compared with MRI.
Level of Evidence
Level II, economic and decision analysis.
Magnetic resonance imaging (MRI) is the predominant diagnostic modality in assessing soft tissue knee pathology. One of the main issues with the use of MRI is the rate of false positive (FP) and false negative (FN) findings,
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
Some of the advantages in using NA in the physician's office are convenience and immediacy of diagnosis as it can be performed as part of an initial patient visit.
The purpose of this analysis is to determine whether NA compared with MRI in the diagnosis and treatment of meniscal tears is cost-effective when evaluated over a 2-year period via patient-reported outcomes. The hypothesis is that improved diagnostic accuracy with NA would lead to less costly care and similar outcomes.
Methods
Literature searches were performed on November 9 and 10, 2017, using the following search terms in PubMed: ((((Quality) AND Life) AND Instruments) AND arthroscopy) AND knee (11 articles identified; 2 articles obtained); PubMed: (((MRI) AND knee) AND quality) AND life (95 articles identified; 6 articles obtained); PubMed: (((knee) AND arthroscopy) AND cost) AND effectiveness (62 articles identified; 4 articles obtained); EBSCO: Quality of Life AND knee AND arthroscopy (100 articles identified; 4 articles obtained).
The base case population evaluated middle-age (mid to late 40s to the early 50s) adults with intra-articular knee damage (medial and/or lateral meniscal damage) presenting with symptoms indicative of a meniscal lesion, who were not contraindicated to completing an MRI, who did not have an infection, and who presented to an orthopaedic physician specializing in arthroscopy with knee pain for several months. Based on clinical work-up, an MRI versus in-office diagnostic NA was indicated. A decision to treat or not was made on the MRI or NA diagnosis.
Modeling the Condition
TreeAge Pro 2017 Markov modeling software was used to evaluate the cost and effectiveness of NA versus MRI in the diagnoses and subsequent treatment based on the findings of both diagnostic modalities based on results in the medical literature. TreeAge Pro is a decision support model accepted by such organizations as the National Institutes for Health and Clinical Excellence (United Kingdom).
The following diagnoses were evaluated: medial and lateral meniscus pathology. Treatment for each condition occurred for true positive (TP) and FP for both NA and MRI findings. For meniscus pathology it was assumed that a partial meniscectomy (medial or lateral; CPT 29881) was performed in symptomatic patients without severe degenerative knee pathology and that subsequent follow-up care provided including physical therapy. The reason a partial meniscectomy was chosen was for simplicity's sake and owing to the fact that it is the dominant procedure performed. True negative (TN) findings were not treated, and it was assumed the patient had no follow-up clinical care. FN findings were followed up with physical therapy first and, if this failed, hyaluronic acid (HA) injections were administered.
Viscosupplementation for osteoarthritis. Blue Cross Blue Shield of Illinois. Health Care Services Corporation. Policy #RX501.049. Effective: July 15, 2017.
HA was administered if patients were in pain or had degenerative disease (e.g., early-stage osteoarthritis); HA treatments are found to be the safest and longest lasting for lowering the pain.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review.
Outcomes for patients undergoing therapy (or not) for suspected knee damage were evaluated for effectiveness using the knee injury and osteoarthritis outcome score (KOOS). KOOS is an instrument mainly used for evaluating osteoarthritis but has also been validated for knee injury.
KOOS4 (mean score for four of five KOOS subscale scores: pain, other symptoms, function in sport and recreation, and knee related quality of life) was used in the model to evaluate the various outcome states the patient exhibited over a 2-year period from baseline. KOOS scores at each time frame were then totaled for an aggregate outcome score. Appendix Table 1 shows the relevant KOOS4 values used in the Markov model at baseline and 1 and 2 years. Outcomes were discounted at 3%.
The direct costs for diagnosis and treatment were based on the 2017 Medicare national average fee schedule and are found in Appendix Table 1. MRI and NA private payer reimbursement rates were based on available data.
Private payment rates were based on an assumed premium of 30% over Medicare rates. Surgical procedures were assumed to take place in the hospital outpatient setting. MRI was assumed to take place in the hospital outpatient setting as well (CPT 73721 + APC 5523; $240 + $219 = $459 for Medicare
and $958 for private pay [Data on file: VisionScope Technologies]). The costs of performing CPT 29870 in the physician office setting are included in CPT 29870 and reflect such expenses as needle arthroscope, cost of the dressing/injection/anesthetic, cost of administration and preparation of the medication and the room (practice expenses), and the time to perform the procedure (physician work). All of these costs are embedded in the relative value units for both physician work and practice expense.
Additionally, it was assumed that the patient population would represent a typical enrollee of either private insurer or Medicare. Complications were also factored into surgical procedures and included deep vein thrombosis, pulmonary embolism, venous thromboembolism, and any other complication requiring a patient be admitted to the hospital. These costs and their incidence were derived from the medical literature.
Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: An administrative claims analysis from 30 managed care organizations.
Based on the probability of a finding of a TP or FP, patients were surgically treated and corresponding health states were assumed postprocedure relating to complications, rehabilitation, and outcome. For FN findings, it was assumed patient first underwent physical rehabilitation. If this failed, patients underwent HA injections, and if those failed, they ultimately underwent surgery
Viscosupplementation for osteoarthritis. Blue Cross Blue Shield of Illinois. Health Care Services Corporation. Policy #RX501.049. Effective: July 15, 2017.
Figure 1 shows the Markov model for diagnosis and treatment for the medial meniscus. Figure 2 shows the structure for Markov state transition diagram for an FP finding. One- and 2-way sensitivity analyses were performed to determine which variables had the greatest effect on overall cost for care. Each variable was varied at least ±25% to determine strength of the findings and to determine the point at which MRI or NA was the preferred diagnostic based on overall costs. Incremental cost effect scatterplot analysis using Monte Carlo simulation (sampling probabilistic sensitivity, run 10,000 times) was performed to determine the percentage of time therapies that were dominant (resulted in overall lower cost with improved outcomes) for each condition. All probabilities of events occurring are identified in Appendix Table 1 for medial meniscus pathology. Four different Markov models were developed: medial and lateral meniscus (using Medicare or private pay information) with appropriate therapeutic follow-up. These models differed slightly based on specificities and sensitivities for MRI and NA (as per Table 1) and for surgical therapy for meniscal damage as well.
Fig 1Decision tree comparing use of needle arthroscopy to magnetic resonance imaging as a diagnostic prior to surgery.
Consolidated health economic evaluation reporting standards (CHEERS)—Explanation and elaboration: A report of the ISPOR health economic evaluations publication guidelines good reporting practices task force.
Appendix Table 2 shows each of the stages (years 0 to 2; with “0” being the initial encounter/procedure) and state transitions for NA and MRI for TP, FP, TN, and FN findings. Each of these stages has an associated probability of occurring, an associated cost, and outcome as measured by KOOS4. The values identified in Appendix Table 2 are for a medial meniscus tear using Medicare costs. Furthermore, each of the TPs, FPs, TNs, and FNs also has an associated probability of occurring based on the literature.
The incremental cost-effectiveness (ICE) scatterplots in Monte Carlo simulation with respect to NA versus MRI dominance using Medicare data are summarized in Table 4 and in Figure 3 (used as an example of an ICE scatterplot). ICE scatterplots in Monte Carlo simulation showed that with private pay rates, NA was dominant to MRI the majority of the time (Table 5). Two-way sensitivity analysis demonstrated that at various costs for both MRI and NA, NA was the less costly alternative in the majority of cases (Table 6). One-way sensitivity demonstrated that the following variables and thresholds affected the model, resulting in a lower cost for MRI versus NA based on Medicare payment amounts (Table 7) and private pay payment amounts (Table 8): cost of NA, cost of MRI, percentage of MRI positives, and percentage of NA positives. Note that all parameters/ranges used can be found in Appendix Table 1 for Medicare (medial meniscus only) and Appendix Table 3 for private pay (medial meniscus only).
Table 4Medicare Data
Condition
Needle Arthroscopy Dominant % of Time
Magnetic Resonance Imaging Dominant % of Time
ICER Ratio for NA
Medial meniscus
61
9
N/A
Lateral meniscus
80
5
N/A
ICER, incremental cost effectiveness ratio; N/A, not applicable.
Fig 3Medial meniscus Medicare incremental cost-effectiveness scatterplot examining the probabilities of incrementally lower or higher costs and knee injury and osteoarthritis outcome scores in using needle arthroscopy versus magnetic resonance imaging.
In analyzing the cost-effectiveness of NA using Markov modeling, NA was found to be less costly than MRI while providing for “equivalent/improved” outcomes. With private payers, MRI reimbursement for the lower limb without contrast, from a recent analysis surveying 1,584 hospitals (and from 3 large private insurers: Aetna, Humana, and United Healthcare), averaged $1,332 ± 509 (2011 data, inflated to 2017 using hospital outpatient medical CPI $1,628 ± $622).
In contrast, internal data collected on CPT 29870 (diagnostic knee arthroscopy; physician office setting) for private payers (Aetna, BCBS, CIGNA, Humana, United Healthcare mainly in the following states: CA, CT, GA, IL, NJ, MA) estimated a reimbursement rate of $958 ± $317 (data available from VisionScope Technologies and consistent with Truven data, $1,175). When using these values in the models, NA dominated MRI.
For this analysis, it was assumed that an MRI for a private pay patient would be performed in the hospital outpatient setting, where reimbursement is highest, $1,628. This is compared with an approximate $1,050 reimbursement rate for an MRI performed in a freestanding MRI facility.
If the MRI value of $1,050 were used in the analysis, NA still would be the least costly in all lesions examined with savings of $1,284 (medial meniscus) and $678 (lateral meniscus). In other words, no matter the setting for an MRI under private pay, NA was the least costly alternative and provided for “equivalent/improved” outcomes. Although the reimbursement rate for MRI and NA may vary across the United States based on negotiated rates between providers and insurers, the private pay reimbursement rates for NA and MRI in this analysis were derived from large data sets and from large payers (Data on file: VisionScope Technologies; Truven 2017 data). In a separate sensitivity analysis of the cost of an MRI (Table 8), the following MRI private pay reimbursements would need to be met for MRI to be the less costly alternative: for the medial meniscus, NA is always the less costly alternative no matter the MRI reimbursement (ranges evaluated in sensitivity analysis $0 to $3,000); for the lateral meniscus, MRI would need to be <$371 (Fig 4).
Fig 4Sensitivity analysis of cost of magnetic resonance imaging (private pay rate) in evaluating a lateral meniscus lesion.
In all clinical scenarios, NA produced superior outcomes versus MRI as measured by KOOS4. The KOOS4 scores as evaluated in this analysis assumed a given treatment paradigm (e.g., all FPs were treated with surgical arthroscopy, and all FNs were treated via surgical arthroscopy if PT and HA injections were first not successful), which may not be the case in actual practice. Specifically, some clinicians may not treat FP findings and FN findings may not deteriorate to the point of requiring an intervention. Thus, the KOOS4 outcomes findings herein may be subject to debate.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
study, the kappa statistics comparing NA with surgical diagnostic arthroscopy (standard bore size arthroscope) were very high, indicating no significant difference between the 2 modalities.
In 1-way sensitivity analysis, MRI has always been more sensitive in medial versus lateral pathology.
Thus, the overall positive finding threshold (TP + FP) for preferring MRI to NA is higher with medial versus lateral pathology (Tables 7 and 8). The lateral meniscus presents challenges based on the oblique orientation of the posterior horn with its sloping upward course at its attachment and small radial curvature. This makes tears of the posterior horn and tears involving less than one-third of the lateral meniscus difficult to identify on MRI.
In these cases, it is likely that the initial use of NA (vs MRI) would have resulted in a more timely treatment of the tear, perhaps with less patient pain over time.
From clinical practice, health policy, and patient satisfaction standpoints, NA may present advantages. NA is a diagnostic procedure that can be performed with the patient awake in a physician's office setting. A diagnosis can then be made by the clinician at that point, with 1 encounter establishing definitive diagnosis and treatment.
Further, considering there can be a significant number of patients who are missed with MRI (i.e., FN findings) for the lateral meniscus pathology,
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review.
inappropriate care may be delivered. Additionally, based on the relatively high incidence of FP findings in medial meniscus pathology, there is the potential for unnecessary surgical treatment. There has been a push recently by policy makers and the medical community to ensure appropriate care is being delivered in all care settings, including emphasizing individual patient needs as the top priority.
This analysis includes private pay reimbursement and outcomes (KOOS4) and examines a patient over a 2-year period. This study also adds further clarity to the effect of NA on private insurers, where the majority of this type of condition is evaluated and treated.
Limitations
Indirect costs were not factored into this analysis. These costs include time absent from work, loss of productivity (owing to pain), out-of-pocket expenses related to transportation, travel time, assistive devices, and time spent on follow-up.
MRI results that were obtained from the literature were derived from academic medical centers where more advanced MRI technology (i.e., higher resolution of intra-articular disease) is available and generally where more experienced musculoskeletal radiologists reside.
KOOS4 was used as a proxy for outcome. This was a global score using 4 of the 5 subscale scores for patient with meniscal tears and osteoarthritis (pain, other symptoms, function in sports and recreation, and knee quality of life). The KOOS4 data were derived from a randomized controlled trial recently completed in middle-age patients (which was the population for this cost-effectiveness evaluation).
Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up.
It was assumed that all patients in the analysis would be willing to undergo NA in the office. This may not be the case, and there may crossover to MRI assessment owing to its noninvasive nature. This crossover was not accounted for in the analysis.
It was assumed that symptomatic patients with TP and FP (with diagnosed pathology—either MRI or NA) were treated arthroscopically for a meniscectomy. This was based on an evidence-based review of meniscal tears after surgery with short-term satisfactory results occurring in approximately 90% of patients.
In other words, there is a high likelihood that patients will benefit from a surgical intervention. Additionally, with respect to FP MRI findings and our assumption that FP went on to surgery, Medicare CPT historical use data for the years 2000 to 2015 have shown a consistency of use for codes 29870 (diagnostic knee arthroscopy) and CPT 29880 plus 29881. CPT codes 29880/29881 have made up 73% to 75% of all surgical knee arthroscopies over this time frame.
CPT 29870 has also made up 1.2% to 1.3% of the 29880/29881 total. Since FPs in MRI are in the 10% to 15% range, the historical use of CPT 29870 should be much higher. It is therefore the assumption that FP MRI results are being treated surgically in everyday practice.
The negative predictive value of MRI and NA has been shown to be quite high in meniscal tears,
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
and unless the patient had clinical symptoms indicative of a meniscal tear (along with a negative MRI and NA), follow-on arthroscopy was not performed. Since this occurs infrequently, surgery was not accounted for in TN findings.
It was assumed patients were treated conservatively at first based on an FN finding. This was based on the standards of care for treating pain.
Ultimately if the patient outcome did not improve, that patient underwent a surgical arthroscopic procedure.
The use of MRI in patients with suspected bony edema (and with joint effusion) may be the more appropriate diagnostic modality versus NA because a differential diagnosis can be obtained. In patients with acute trauma with joint effusion, MRI can provide additional diagnostic capabilities regarding the condition of subchondral bone and alternative treatment(s).
MRI-detected subchondral one marrow signal alterations of the knee joint: Terminology, imaging appearance, relevance and radiological differential diagnosis.
This was not evaluated in this analysis and is a limitation of the data evaluated.
Last, the cost analysis covers 2 years only. Therefore, the findings of cost savings should be restricted to this time frame.
Conclusions
Based on the reported MRI incidence of FPs with the medial meniscus and FNs with the lateral meniscus based on assumed standards of care, more costly care is provided when using MRI compared with NA. Outcomes were similar with NA compared with MRI.
Appendix
Appendix Table 1Variables and Distributions Used in the Markov Model for Medicare
Variables Used in the Model: Medial Meniscus Assessment/Treatment
Name
Description
Formula
Value
Low
High
Comment
Anesthesia_outpatient_meniscectomy
CPT 01400: anesthesia for a 30-minute arthroscopic meniscectomy hospital outpatient setting
$132
$132
$0
$132
Base units = 4; 1 unit each for 15 minutes of patient being under; total of 6 units. CMS 2017 CF = $22.05. Therefore, 6 units × $22.05 = $132.30
APC_arthroscopic_meniscectomy
APC 5113: facility payment for surgical meniscectomy
$2,425
$2,425
$0
$2,425
APC 5113: for use with CPT 29881. Medicare 2017 fee schedule.
Medicare 2017 national average payment amount for arthrocentesis and/or corticosteroid injection.
Cost_DVT
Cost to treat a DVT over a 12-month period
$16,322
$16,322
$0
$0
Source: Spyropoulos AC, Lin J. Direct medical costs of VTE and subsequent hospital readmission rates: An administrative claims analysis form 30 managed care organizations. J Manag Care Pharma 2007;13:475-486. Costs inflated using medical CPT from 2007 to 2017.
Cost_orthopedic_readmit_comp
Cost orthopedic readmit owing to comp: DRG 565
$6,623
$6,623
$0
$12,000
Medicare 2017 national average payment for DRG 565: OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC
Cost_PE
Cost to treat a PE over a 12-month period
$25,144
$25,144
$0
$40,000
Source: Spyropoulos AC, et al. (2007). Costs inflated using medical CPT from 2007 to 2017.
Cost_VTE
Cost to treat a VTE over a 12-month period
Cost_complication_VTE
$25,730
$0
$40,000
Source: Lin J, Lingohr-Smith M, Kowng WJ. Incremental health care resource utilization and economic burden of venous thromboembolism recurrence from a US payer perspective. Jrl Manag Care Pharm 2014;20:174-186.
Cost_Wound_comp_arthroscopic_lavage_drainage
CPT 29871: arthroscopic lavage and drainage for infection + APC 5113
$2,956
$2,956
$0
$5,000
Medicare 2017 national average payment rate for arthroscopic lavage and drainage: infection plus APC 5113 at $2,425.
CPT_arthroscopic_meniscectomy
CPT 29881: partial meniscectomy, medial or lateral
$558
$558
$0
$1,000
Medicare 2017 national average payment amount for a meniscectomy of the knee: medial or lateral; facility setting.
Average private payer rates for NA obtained from explanation of benefits for various payers, including Blue Cross Blue Shield, Aetna, United, CIGNA, Harvard Pilgrim Health Plan. Mean ± SD = $958 ± $317.
CPT_Evaluation_Mgmt_Existing
CPT code for a follow-up evaluation and management on an existing patient
$109
$109
$0
$200
Medicare 2017 national average payment amount for a 30-minute physical examination: existing patient.
CPT_Evaluation_Mgmt_existing_injection
Cost E&M for injection corticosteroid: CPT 99212
$44
$44
$0
$100
Medicare 2017 national average payment rate: CPT 99212.
CPT_Evaluation_Mgmt_New
CPT code for evaluation and management: patient history and examination
$166
$166
$0
$300
Medicare 2017 national average payment amount for a 30-minute physical examination: new patient.
CPT_MRI_knee_Medicare
CPT 73721: MRI knee without contrast, Medicare
$240
$240
$0
$1,500
Medicare 2017 national average payment amount for an MRI of the knee without contrast.
CPT_MRI_Knee_PP
CPT 73721: MRI knee without contrast, private pay
$1,628
$1,628
$0
$3,000
Cooper Z, Craig SV, Gaynor M, Van Reenen J. The price ain’t right? Hospital prices and health spending on the privately insured. Working paper 21815. National Bureau of Economic Research. Published December 2015. Revised May 2018. The 2011 reimbursement rates are inflated to 2017.
CPT_Xray_knee
CPT 73564 x-ray knee: 4 views
$40
$40
$0
$80
Medicare 2017 national average payment amount for x-rays of the knee: 4 views.
KOOS4_baseline_score
KOOS4_baseline
56.95
0
85
Source: Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016;354:i3740.
KOOS4_one_year_exercise
KOOS4_excercise_one_year
82.53
0
90
Source: Kise NJ, et al. (2016).
KOOS4_one_year_meniscectomy
KOOS4_meniscectomy_one_year
86.93
0
95
Source: Kise NJ, et al. (2016).
KOOS4_two_year_exercise
KOOS4_exercise_two_years
88.2
0
95
Source: Kise NJ, et al. (2016).
KOOS4_two_year_meniscectomy
KOOS4_meniscectomy_two_years
87.4
0
95
Source: Kise NJ, et al. (2016).
MRI_positives
MRI positive findings out of all findings (positive + negative)
Positive_findings_MRI
55%
0%
99%
Crawford R, Walley G, Bridgman S, Mafulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review. Br Med Bull 2007;84:5-23.
NA_positives
Needle arthroscopy positive findings out of all NA findings (positive + negative)
Positive_findings_NA
43%
0%
99%
Based on VisionScope NA findings. Data on file.
Physical_therapy_cost_week
Cost physical therapy per week
$660
$660
$0
$15,000
CPT 97110 pays at $33 per 15-minute session. Assume 4 sessions per day; 5 days per week. Therefore, $33 × 4 × 5 = $660 per week.
Physical_therapy_initial_evaluation
CPT 97162: initial evaluation for physical therapy
$83
$83
$0
$150
Medicare 2017 national average payment for CPT 97162: initial evaluation for physical therapy.
Physical_therapy_knee
Physical therapy knee: assume 3-6 weeks
Physical_therapy_duration_post_surg
4.5
0
9
Assumed course of physical therapy based on coverage determinations of Medicare and private payers.
Probability_comp_DVT
Probability DVT meniscal surgical arthroscopic procedure
0.12%
0.12%
0%
1%
Source: Jameson SS, Dowen D, James P, Serrano-Pedraza I, Reed MR, Deehan DJ. The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg Br 2011;93:1327-1333.
Probability_comp_PE
Probability PE meniscal surgical arthroscopic procedure
0.08%
0.08%
0%
0.2%
Source: Jameson SS, et al. (2011).
Probability_comp_readmit
Probability readmit owing to meniscal surgical arthroscopic procedure
0.45%
0.45%
0%
1%
Source: Jameson SS, et al. (2011).
Probability_comp_VTE
Probability VTE meniscal arthroscopic surgical procedure
0.19%
0.19%
0%
0.5%
Source: Jameson SS, et al. (2011).
Probability_comp_wound
Probability wound complication meniscal arthroscopic surgical procedure
0.11%
0.11%
0%
0.5%
Source: Jameson SS, et al. (2011).
Probability_complication
Probability complication post knee surgery
Probability_complication_knee_arthroscopy
1%
0%
2%
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month time frame. Derived from the medical literature and inflated to 2017.
Probability_pain_meds_success
Probability corticosteroid injections relived pain symptoms
50%
50%
0%
90%
Estimated.
Probability_rehab_post_med_failure
Probability exercise rehabilitation post medication failure
85%
85%
0%
95%
Source: Cavanaugh JT, Killian SE. Rehabilitation following meniscal repair. Curr Rev Musculoskelet Med 2012;5:46-58.
Probability_rehab_success
Probability rehab success post meniscectomy
Probability_meniscal_repair_success
80%
0%
90%
Source: Cavanaugh JT, et al. (2012)
TN_MRI
True_negatives_MRI
90%
0%
95%
Crawford R, et al. (2007).
TN_NA
True_Negatives_NA
86%
0%
99%
Based on VisionScope NA findings. Data on file.
TP_MRI
True_positives_MRI
83%
0%
95%
Crawford R, et al. (2007).
TP_NA
True_positives_NA
97%
0%
99%
Based on VisionScope NA findings. Data on file.
Weighted_average_complication_cost
Weighted_average_cost_complication
$12,804
$0
$20,000
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month time frame. Derived from the medical literature and inflated to 2017.
Distributions Used in the Model
Description
Type
Parameters
EV
Comment
Physical therapy in weeks after arthroscopic meniscal surgery
Uniform
Subtype: 2, low: 3, high: 6
4.5
Assumed course of physical therapy based on coverage determinations of Medicare and private payers.
Cost of treating a VTE over a 12-month period, Medicare
Normal
Mean: 25730; SD: 40,250
$25,730
Source: Lin J, et al. (2014).
Weighted average cost of a complication post arthroscopy
Normal
Mean: 12804; SD: 10,000
$12,804
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month time frame. Derived from the medical literature and inflated to 2017.
Percentage of positive findings on MRI vs total findings
Uniform
Subtype: 2; low: 0.4; high: 0.7
55%
Assumed positive findings for medial meniscus pathology for MRI.
Percentage of TNs of all negative findings MRI (TN + FN)
Uniform
Subtype: 2; low: 0.85; high: 0.95
90%
Assumed negative findings for medial meniscus pathology for MRI.
KOOS4 at 2-year exercise group
Triangular
Min: 81.1; likeliest: 85; max: 98.5
88.2
Source: Kise NJ, et al. (2016).
Probability of meniscus repair success post rehab
Uniform
Subtype: 2; low: 0.7; high: 0.9
80.0%
Source: Cavanaugh JT, et al. (2012).
Percentage of positive findings of all findings NA (TP + FP)
Uniform
Subtype: 2; low: 0.4; high: 0.45
42.5%
Based on VisionScope NA findings. Data on file.
Probability knee complication
Triangular
Min: 0.001; likeliest: 0.0095; max: 0.02
1.02%
Probability of a complication based on all complications summed up: 0.95%
Percentage of TN NA of all negatives (TN + FN)
Triangular
Min: 0.725; likeliest: 0.882; max: 0.967
85.8%
Based on VisionScope NA findings. Data on file.
KOOS4 at 1-year exercise
Triangular
Min: 74.9; likeliest: 79.5; max: 93.2
82.53
Source: Kise NJ, et al. (2016).
Percentage of TPs of all positives (TP + FP)
Triangular
Min: 0.922; likeliest: 0.986; max: 1
96.9%
Based on VisionScope NA findings. Data on file.
Percentage of TPs of all positive MRI findings (TP + FP)
Uniform
Subtype: 2; low: 0.8; high: 0.85
82.5%
Crawford R, et al. (2007).
KOOS4 at 2-year meniscectomy
Triangular
Min: 80.4; likeliest: 84.1; max: 97.7
87.4
Source: Kise NJ, et al. (2016).
KOOS4 at 1-year meniscectomy
Triangular
Min: 79.9; likeliest: 83.7; max: 97.2
86.93
Source: Kise NJ, et al. (2016).
KOOS4 baseline score meniscus damage
Normal
Mean: 56.95; SD: 16.37
56.95
Source: Kise NJ, et al. (2016). Combined mean from exercise and meniscectomy groups: N = 70 both groups; mean ± SD exercise: 54.3 ± 18.2 and meniscectomy: 59.6 ± 13.8.
APT, Ambulatory Payment Classification; CPT, Current Procedure Terminology; DRG, Diagnosis Related Group; DVT, deep vein thrombosis; E&M, evaluation and management; EV, expected value; FN, false negative; FP, false positive; KOOS, knee injury and osteoarthritis outcome score; MRI, magnetic resonance imaging; NA, needle arthroscopy; PE, pulmonary embolism; SD, standard deviation; TN, true negative; TP, true positive; VTE, venous thromboembolism.
Appendix Table 3Variables and Distributions Used in the Private Pay Model
Private Pay Variables
Name
Description
Formula
Value
Low
High
Comment
Anesthesia_outpatient_meniscectomy
CPT 01400: anesthesia for a 30-minute arthroscopic meniscectomy, hospital outpatient setting
$180
$180
$0
$250
Base units = 4; 1 unit each of 15 minutes of patient being under; total of 6 units. CMS 2017 CF = $22.05. Therefore, 6 units × $22.05 = $132.30. Assuming a 30% markup for private pay over Medicare = 132 × 1.3 = 180.
APC_arthroscopic_meniscectomy
APC 5113: facility payment for surgical meniscectomy
$3,153
$3,153
$0
$4,000
APC 5113: for use with CPT 29881. Assume 30% markup for private pay: $2425 × 1.3 = 3153.
Cost_HA_injection
Use of Medicare J7323 Euflexxa per dose = $155
$155
$155
$0
$500
Derived from Medicare payment rate for J7323 at $155.
CPT_arthroscopic_meniscectomy
CPT 29881: partial meniscectomy, medial or lateral
$725
$725
$0
$1,000
Medicare 2017 national average payment amount for a meniscectomy of the knee: medial or lateral; facility setting. Assume 30% markup of private pay over Medicare: $558 × 1.3 = $725.
Private payer national average payment amount for a diagnostic knee arthroscopy: physician office setting. Data on file VisionScope.
CPT_Evaluation_Mgmt_Existing
CPT code for a follow-up evaluation and management on an existing patient
$142
$142
$0
$180
Medicare 2017 national average payment amount for a 30-minute physical examination: existing patient. Assume 30% markup of private pay over Medicare: $109 × 1.3 = $142.
CPT_Evaluation_Mgmt_existing_injection
Cost E&M for injection corticosteroid: CPT 99212
$57
$57
$0
$100
Medicare 2017 national average payment rate: CPT 99212. Assume 30% markup of private pay over Medicare: $44 × 1.3 = $57.
CPT_Evaluation_Mgmt_New
CPT code for evaluation and management: patient history and examination
$216
$216
$0
$300
Medicare 2017 national average payment amount for a 30-minute physical examination: new patient. Assume 30% markup of private pay over Medicare: $166 × 1.3 = $216.
CPT_MRI_knee
CPT 73721: MRI knee without contrast
MRI_knee
$1,628
$0
$3,000
Private pay 2017 national average payment amount for an MRI of the knee without contrast: hospital setting. Truveen data.
CPT_Xray_knee
CPT 73564 x-ray knee: 4 views
$52
$52
$0
$100
Medicare 2017 national average payment amount for x-rays of the knee: 4 views. Assume 30% markup of private pay over Medicare rate: $40 × 1.3 = $52.
HA_injection
CPT 20610: arthrocentesis and/or injection
$81
$81
$0
$160
Medicare 2017 national average payment amount for arthrocentesis and/or corticosteroid injection. Assume 30% markup of private pay over Medicare: 62 × 1.3 = 81.
KOOS4_baseline_score
KOOS4_baseline
56.95
0.00
80.00
Source: Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016;354:i3740.
KOOS4_one_year_exercise
KOOS4_excercise_one_year
82.53
0.00
90.00
Source: Kise NJ, et al. (2016).
KOOS4_one_year_meniscectomy
KOOS4_meniscectomy_one_year
86.93
0.00
95.00
Source: Kise NJ, et al. (2016).
KOOS4_two_year_exercise
KOOS4_exercise_two_years
88.20
0.00
95.00
Source: Kise NJ, et al. (2016).
KOOS4_two_year_meniscectomy
KOOS4_meniscectomy_two_years
87.40
0.00
95.00
Source: Kise NJ, et al. (2016).
MRI_positives
MRI positive findings out of all findings (positive + negative)
Positive_findings_MRI
55.0%
0.0%
99.0%
Crawford R, Walley G, Bridgman S, Mafulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review. Br Med Bull 2007;84:5-23.
NA_positives
Needle arthroscopy positive findings out of all NA findings (positive + negative)
Positive_findings_NA
42.5%
0.0%
99.0%
Based on VisionScope NA findings. Source: Gill TJ, Safran M, Mandelbaum B, Huber B, Gambardella R, Xerogeanes J. A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy. Arthroscopy 2018;34:2429-2435.
Physical_therapy_cost_week
Cost of physical therapy per week
858
$858
$0
$1,500
CPT 97110 pays at $33 per 15-minute session. Assume 4 sessions per day; 5 days per week. Therefore, $33 × 4 × 5 = $660 per week. Assume 30% markup of private pay over Medicare: $660 × 1.3 = $858.
Physical_therapy_initial_evaluation
CPT 97162: initial evaluation for physical therapy
108
$108
$0
$200
Medicare 2017 national average payment for CPT 97162: initial evaluation for physical therapy. Assume 30% markup of private payer over Medicare: $83 × 1.3 = $108.
Probability_complication
Probability complication post knee surgery
Probability_complication_knee_arthroscopy
1.0%
0.0%
10.0%
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month timeframe. Derived from the medical literature and inflated to 2017.
Probability_HA_success
Probability that HA is successful in relieving pain
HA_effectiveness
75.7%
0.0%
90.0%
Source: Concoff A, Sancheti P, Niazi F, Shaw P, Rosen J. The efficacy of multiple versus single hyaluronic acid injections: A systematic review and meta-analysis. BMC Musculoskel Disord 2017;18(1):542.
Probability_pain_meds_success
Probability corticosteroid injections relieved pain symptoms
0.5
50.0%
0.0%
80.0%
Estimated
Probability_rehab_post_med_failure
Probability exercise rehabilitation post medication failure
0.85
85.0%
0.0%
95.0%
Source: Cavanaugh JT, Killian SE. Rehabilitation following meniscal repair. Curr Rev Musculoskelet Med 2012;5:46-58.
Probability_rehab_success
Probability rehab success post meniscectomy
Probability_meniscal_repair_success
80.0%
0.0%
90.0%
Source: Cavanaugh JT, et al. (2012).
TN_MRI
True_negatives_MRI
90.0%
0.0%
95.0%
Crawford R, et al. (2007).
TN_NA
True_Negatives_NA
85.8%
0.0%
99.0%
Based on VisionScope NA findings. Source: Gill TJ, et al. (2018).
TP_MRI
True_positives_MRI
82.5%
0.0%
90.0%
Crawford R, et al. (2007).
TP_NA
True_positives_NA
96.9%
0.0%
99.0%
Based on VisionScope NA findings. Source: Gill TJ, et al. (2018).
Weighted_average_complication_cost
Weighted_average_cost_complication
$12,804
$0
$20,000
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month time frame. Derived from the medical literature and inflated to 2017.
Private Pay Distributions
Name
Description
Type
Parameters
EV
Comment
Physical_therapy_duration_post_surg
Physical therapy in weeks post arthroscopic meniscal surgery
Uniform
Subtype: 2; low: 3; high: 6
4.5
Assumed course of physical therapy based on coverage determinations of Medicare and private payers.
Cost_complication_VTE
Cost of treating a VTE over a 12-month period: Medicare
Normal
Mean: 25,730; SD: 40,250
$25,730
Source: Lin J, Lingohr-Smith M, Kowng WJ. Incremental health care resource utilization and economic burden of venous thromboembolism recurrence from a US payer perspective. Jrl Manag Care Pharm 2014;20:174-186.
Weighted_average_cost_complication
Weighted average cost of a complication post arthroscopy
Normal
Mean: 12,804, standard deviation: 10000
$12,804
Weighted average cost of DVT, PE, VTE, readmit, wound complication based on the probabilities of occurrence and over a 12-month time frame. Derived from the medical literature and inflated to 2017.
Positive_findings_MRI
Percentage of positive findings on MRI vs total findings
Uniform
Subtype: 2, low: 0.4, high: 0.7
55%
Assumed positive findings for medial meniscus pathology for MRI.
True_negatives_MRI
Percentage of TNs of all negative findings MRI (TN + FN)
Uniform
Subtype: 2, low: 0.85, high: 0.95
90%
Assumed negative findings for medial meniscus pathology for MRI.
KOOS4_exercise_two_years
KOOS4 at 2-year exercise group
Triangular
Min: 81.1, likeliest: 85, max: 98.5
88.2
Source: Kise NJ, et al. (2016).
HA_effectiveness
HA effectiveness in relieving pain
Triangular
Min: 0.53, likeliest: 0.76, max: 0.98
75.7%
Source: Concoff A, et al. (2017).
Probability_meniscal_repair_success
Probability of meniscus repair success post rehab
Uniform
Subtype: 2, low: 0.7, high: 0.9
80.0%
Source: Cavanaugh JT, et al. (2012.
NA_knee
Private payer amount NA POS
Normal
Mean: 958, standard deviation: 317
$958
Data on file VisionScope; 400 plus data points from private insurers.
Positive_findings_NA
Percentage of positive findings of all findings NA (TP + FP)
Uniform
Subtype: 2, low: 0.4, high: 0.45
42.50%
Source: Gill TJ, et al. (2018).
Probability_complication_knee_arthroscopy
Probability of knee complication
Triangular
Min: 0.001, likeliest: 0.0095, max: 0.02
1.02%
Probability of a complication based on all complications summed up: 0.95%.
True_Negatives_NA
Percentage of TNs NA of all negatives (TN + FN)
Triangular
Min: 0.725, likeliest: 0.882, max: 0.967
85.80%
Source: Gill TJ, et al. (2018).
KOOS4_excercise_one_year
KOOS4 at 1-year exercise
Triangular
Min: 74.9, likeliest: 79.5, max: 93.2
82.533
Source: Kise NJ, et al. (2016).
True_positives_NA
Percentage of TPs of all positives (TP + FP)
Triangular
Min: 0.922, likeliest: 0.986, max: 1
96.93%
Source: Gill TJ, et al. (2018).
True_positives_MRI
Percentage of TPs of all positive MRI findings (TP + FP)
Uniform
Subtype: 2, low: 0.8, high: 0.85
82.50%
Source: Crawford R, et al. (2007).
KOOS4_meniscectomy_two_years
KOOS4 at 2-year meniscectomy
Triangular
Min: 80.4, likeliest: 84.1, max: 97.7
87.4
Source: Kise NJ, et al. (2016).
KOOS4_meniscectomy_one_year
KOOS4 at 1-year meniscectomy
Triangular
Min: 79.9, likeliest: 83.7, max: 97.2
86.933
Source: Kise NJ, et al. (2016).
KOOS4_baseline
KOOS4 baseline score meniscus damage
Normal
Mean: 56.95, standard deviation: 16.37
56.95
Source: Kise NJ, et al. (2016). Combined mean from exercise and meniscectomy groups: N = 70 both groups. Mean ± SD exercise: 54.3 ± 18.2 and meniscectomy: 59.6 ± 13.8.
MRI_knee
Private payer rate MRI knee
Normal
Mean: 1628, standard deviation: 622
$1,628
Available from Truven Analytics.
CPT, Current Procedural Terminology; DVT, deep vein thrombosis; E&M, evaluation and management; EV, expected value; HA, hyaluronic acid; FN, false negative; FP, false positive; KOOS, knee injury and osteoarthritis and outcome score; MRI, magnetic resonance imaging; NA, needle arthroscopy; PE, pulmonary embolism; POS, physician office setting; SD, standard deviation; TN, true negative; TP, true positive; VTE, venous thromboembolism.
A prospective, blinded, multicenter clinical trial to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging and surgical arthroscopy.
Viscosupplementation for osteoarthritis. Blue Cross Blue Shield of Illinois. Health Care Services Corporation. Policy #RX501.049. Effective: July 15, 2017.
Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review.
The price ain’t right? Hospital prices and health spending on the privately insured.
December 2015 (Working paper 21815. National Bureau of Economic Research. https://www.nber.org/papers/w21815.pdf. Published December 2015. Revised May 2018. Accessed December 17, 2018.)
Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: An administrative claims analysis from 30 managed care organizations.
Consolidated health economic evaluation reporting standards (CHEERS)—Explanation and elaboration: A report of the ISPOR health economic evaluations publication guidelines good reporting practices task force.
Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up.
MRI-detected subchondral one marrow signal alterations of the knee joint: Terminology, imaging appearance, relevance and radiological differential diagnosis.
The authors report the following potential conflicts of interest or sources of funding: N.A. receives support from Trice , Pacira , Smith and Nephew , and DePuy . T.C. receives support from Trice and Arthrex . J.X. receives support from Trice and Arthrex . J.V. receives support from Trice . Funding for this analysis was provided by an unrestricted grant from Trice Medical . Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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