Photo Credit: Svitlana

The following is a summary of “Impact of Insurance and Implant Coverage on Arthroscopic Shoulder Surgery Patients: A Prospective Multicenter Analysis,” published in the April 2025 issue of the Journal of Shoulder and Elbow Surgery by Jarrett et al. 

Recent advancements in implant technology have significantly enhanced the outcomes of arthroscopic shoulder surgery, offering patients recovery experiences comparable to traditional open procedures but with reduced morbidity, shorter rehabilitation periods, and improved overall quality of life. Despite these clinical benefits, disparities in insurance coverage—particularly within the U.S. healthcare system—pose barriers to equitable access. Commercial insurers are more likely to cover advanced arthroscopic implants, while governmental insurance plans, such as Medicare and Medicaid, often lack consistent reimbursement for these technologies. To better understand how insurance type and implant coverage influence surgical care, researchers conducted a prospective, multicenter study encompassing 326 arthroscopic shoulder surgeries across six U.S. states. Patients were enrolled at the time of surgical confirmation, and data collection included demographic and clinical variables such as age, sex, race, body mass index, and the American Society of Anesthesiologists (ASA) score. 

Insurance coverage was categorized into commercial, traditional Medicare, Medicare Advantage, Medicaid, workers’ compensation, cash payers, and other governmental plans. Surgical details—such as location (hospital-based operating room vs. freestanding ambulatory surgery center or ASC), time to surgery, number of anchors used, surgery type (primary or revision), use of biologic or structural grafts, and primary surgical indication—were recorded. Results indicated that patients treated in hospital-based settings were generally older (mean age 56.8 vs. 52.0 years), had higher BMI (31.3 vs. 29.0), higher ASA scores (2.4 vs. 1.9), and were more likely to be non-white (41.2% vs. 31.5%) compared to those treated in ASCs (all p<0.05). Even after adjusting for comorbidities, patients with Medicare Advantage (71%), Traditional Medicare (55%), and Medicaid or cash payment (66%) were significantly more likely to undergo surgery in hospital settings than patients with commercial insurance (42%) (p<0.05). 

Additionally, hospital-based patients experienced a longer average wait time before surgery (45.9 vs. 34.4 days, p<0.05). While the number of anchors used was not significantly influenced by insurance type (p=0.58), biologic or structural grafts were used more frequently in hospital cases (19.6%) compared to ASCs (10.4%) (p=0.03). These findings suggest that insurance type—particularly the lack of implant coverage by governmental plans—may indirectly dictate not only the site of service but also influence access to timely and potentially more advanced surgical care. The delayed intervention and site-dependent resource availability associated with governmental insurance could contribute to disparities in outcomes for patients with shoulder pathology. 

To promote equity in surgical care, particularly for populations dependent on public insurance, policymakers should re-evaluate implant coverage policies to support broader, more timely access to arthroscopic shoulder surgery, especially in lower-cost and higher-efficiency settings like ASCs. Addressing these disparities could lead to improved patient outcomes, reduced healthcare costs, and a more equitable surgical landscape.

Source: jshoulderelbow.org/article/S1058-2746(25)00267-8/abstract