The Price of Prophylactic Fixation of the Humerus: A Nationwide Analysis of Negotiated Payor Rates.

BACKGROUND

Metastatic disease in the humerus presents with severe pain, compromised upper extremity function, and impending or completed pathologic fractures. Prophylactic fixation can improve quality of life, yet little is known about the variability in negotiated payor rates for this procedure, which may influence surgical decision making. The objective of this study was to examine factors associated with variations in negotiated payor rates for prophylactic fixation of the proximal humerus.

METHODS

A cross-sectional analysis of negotiated payor rates for current procedural terminology (CPT) code 23491 (prophylactic fixation of the proximal humerus) was conducted using data from the Turquoise Health database. Hospital size was categorized by total bed capacity; payor classes included commercial, Medicare Advantage, managed Medicaid, veterans' affairs, workers' compensation, dual Medicare-Medicaid, exchange plans, and self-pay. Rural-Urban Commuting Area (RUCA) codes, Area Deprivation Index (ADI), and median household income were used to characterize regional factors. Statistical analyses were conducted in R version 4.2.3.

RESULTS

A total of 88,858 negotiated payor rates were evaluated. The average negotiated payor rate in the sample was $11,088. Hospitals with a bed capacity of 1,000-1,500 had the highest mean rates (a +$577 difference from the 0-100 bed reference group, p < 0.0001), whereas mid-sized hospitals (300-500 beds) had significantly lower rates (-$220 difference, p < 0.0001). Workers' compensation yielded the highest rates, exceeding self-pay by $11,620 (p < 0.0001). Metropolitan hospitals, on average, had lower rates than non-metropolitan hospitals ($575 difference, p < 0.0001). Median household income was associated with a clinically insignificant increase in rates ($0.005 per dollar, p < 0.0001), while ADI showed no significant effect.

CONCLUSIONS

Substantial variability in negotiated payor rates for prophylactic fixation of the humerus was evident across hospital sizes, payor types, and geographic contexts. These findings underscore the importance of transparent negotiations and value-based reimbursement frameworks to ensure equitable, cost-effective access to orthopaedic oncology care.