The Affordable Care Act and Global Budget Revenue: The Impact on Total Hip Arthroplasties

Maryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.).

We identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods.

After GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (−4.2% vs −1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (−3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (−$1780.80 vs −$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected ( P = .001). The DID also found decreased costs for patients under GBR ( P < .001 for both).

Maryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.