State-Level Healthcare Policies and Socioeconomic Factors Associated with Total Ankle Arthroplasty Pricing Variations

Research Type: Level 4 – Case series Introduction/Purpose: Total Ankle Arthroplasty (TAA) is increasingly utilized for end-stage ankle arthritis due to advancements in surgical technology and improving patient-reported outcomes. While TAA demonstrates higher initial complication rates, its long-term benefits, including reduced adjacent joint arthritis and fewer subsequent surgeries, may enhance its cost-effectiveness compared to ankle arthrodesis. Recent healthcare transparency initiatives have revealed significant regional variability in TAA pricing across the United States. This variation appears influenced by state-level political dynamics, healthcare regulations, and socioeconomic factors. Understanding these price determinants is crucial as TAA utilization continues to rise. This study investigates how state-level political affiliation, Certificate of Need (CON) laws, and Medicaid expansion impact TAA pricing nationwide, with a specific focus on North Carolina's diverse healthcare landscape. Methods: Data was sourced from the Turquoise Health Database, analyzing TAA prices from 2021 onwards across 29,770 cases at 1,393 hospitals. This cross-sectional study used hospital-level analysis, with price defined as the negotiated hospital facility fee for TAA procedures (CPT code 27702), exclusive of physician fees. Prices outside the 10th and 90th percentiles were excluded to minimize outlier effects. Political affiliation was assessed using two approaches: a composite score integrating five indicators of state political control (state House majority, state Senate majority, governor's party, presidential vote, and Insurance Commissioner affiliation) and the Cook Partisan Voting Index (PVI) for granular analysis. Multivariable regression analyses evaluated relationships between TAA prices and factors including CON regulations, Medicaid expansion, political affiliation, and socioeconomic variables. For North Carolina, additional analyses incorporated Area Deprivation Index (ADI) and urban-rural classification. Results: Analysis revealed that states with CON regulations demonstrated significantly lower TAA prices, with average savings of $1,650 (p < 0.0001). Medicaid expansion correlated with higher prices, showing an average increase of $1,690 (p < 0.0001). While the composite political score showed minimal effect (p=0.9139), the Cook PVI indicated significantly higher prices in Republican-leaning states (p=0.0347). In North Carolina's focused analysis of 254 cases across 35 hospitals, regions with higher ADI scores (>85) correlated with reduced TAA prices by $15,331.50 (p < 0.001). These relationships likely reflect facility-level factors, including provider market power and hospital system consolidation, rather than state-level policy factors alone. Conclusion: Healthcare policy influences TAA pricing through varying mechanisms. CON laws appear to moderate costs through capital expenditure control, while Medicaid expansion correlates with higher prices due to cost-shifting and increased demand. Future longitudinal studies should examine price differences before and after policy implementation to better assess causal relationships. These findings provide essential insights for developing targeted healthcare policies that balance hospital market concentration with equitable access to care, particularly as healthcare systems work to optimize cost control without compromising service delivery.