When hospitals scrutinize the cost of fracture care, the implant is usually the first line item they circle. Douglas R. Dirschl, MD, argues it is often the wrong place to look.
“We really tend to focus on the cost of the implants, and certainly that’s an important part of the cost,” Dr. Dirschl, professor and chair of the Joseph Barnhart Department of Orthopedic Surgery at Baylor College of Medicine in Houston, told Becker’s. “But when you think about a serious fracture that requires hospitalization, it’s really a small percentage of the total cost of that episode of care.”
His argument: Spending more on the implant can pay off across the full episode of care. If a costlier construct gets a patient walking the next day, that patient may leave the hospital sooner, need less intensive post-acute care or skip the skilled nursing facility entirely, and recover faster. This outcome, in his view, could outweigh the higher hardware bill and improve outcomes along the way.
One fracture, two price tags
Dr. Dirschl pointed to a complex distal femur fracture. Surgeons typically fix it with either a plate or a nail, after which the patient can’t bear weight on the limb for about six weeks. That stretches the hospital stay, since the patient needs more days to mobilize, and often means intensive home healthcare or a stint in a skilled nursing facility, followed by a slower recovery.
Surgeons can now use a plate and a nail together in the same fracture. “That’s double the implant cost,” he said. “If we only look at fracture care by implant cost, that’s clearly the wrong strategy.”
Across the full episode, the math shifts. With the combined construct, the patient may stand and walk the next day, leave the hospital sooner, skip the skilled nursing facility or need less intensive post-acute care, and recover faster. The pricier construct, Dr. Dirschl said, may prove the better economic strategy for that patient — and an even better one for functional recovery.
“If we’re going to spend a little bit more money on the implant, but gain the return in the patient’s outcome, maybe that’s something worth thinking about,” he said.
Not on the hospital’s ledger
The obstacle is less clinical than structural. Payers have not bundled fracture care the way they have arthroplasty, so hospitals see the implant bill but not the downstream savings. The hospital’s argument, as Dr. Dirschl described it, is simple: It manages inpatient costs, while the cost of skilled nursing, postoperative physical therapy and rehab sits on someone else’s books.
For acute inpatient fractures, payer pushback is limited, he said, because the patient can’t leave the hospital without treatment. The resistance comes from the hospital instead, which reviews its cost data and flags the outlier.
“Hey, Dirschl, why are your implant costs for a distal femur fracture double that of the next person?” he said, describing that conversation. He said that it’s a tough sell for executives to agree to larger implant investments without a return on that investment.
Surgeons, meanwhile, already lean toward the long view. “Surgeons’ minds are already aligned for longer-term outcomes,” Dr. Dirschl said. Hospitals, less so, and payers may not yet be examining the trade-off closely.
The one change Dr. Dirschl said he would most like to see is alignment between hospitals and physicians on how long outcomes are measured.
“If I treat a fracture and the patient has an infection at day 31, it doesn’t affect the hospital’s metrics at all,” he said. “But yet that patient still has an infection and needs more care.”
Why fractures resist the bundle
Even with aligned incentives, fracture care is harder to standardize than joint replacement. No two fractures, and no two patients, are the same.
“The right way to treat a fracture might be four different ways in four different patients based on the patient, the fracture pattern, and their functional goals and lifestyle,” Dr. Dirschl said.
That contrasts with total hip or knee replacement, which he described as essentially the same operation performed hundreds of thousands of times a year in the U.S. Ankle fractures are treated even more often, he said, but not with the same surgery, in the same patients or toward the same goals.
Proving the value of a costlier implant across that variation will take large volumes of data. “This is probably not going to occur hospital by hospital,” he said. “It’s going to require some very large numbers, entire health systems, maybe nationwide health systems or nationwide payers.”
What would tip the math
Dr. Dirschl sees two paths. Payers could bundle fracture care and hold providers responsible for a 90-day episode or another defined window. Or large integrated systems, which carry both inpatient and post-acute costs, could adopt the approach and demonstrate the results.
Until then, the burden falls on individual surgeons to defend a higher implant bill to a hospital that sees only part of the return. For leaders reviewing orthopedic spend, the question is whether that review stops at the implant — or follows the patient home.
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