Abstract
Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual). To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019. The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge. The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital. In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals. The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.
Highlights
The Medicare program is increasingly focusing on value-based payments to reduce costs and improve quality of care
An episode-level triple-difference analysis indicated that total spending under the Care for Joint Replacement (CJR) model decreased at high-dual hospitals and low-dual hospitals
Meaning The findings suggest that, under the Comprehensive Care for Joint Replacement system, hospitals with a high percentage of disadvantaged patients must reduce spending more substantially than their counterparts to obtain a financial incentive despite their high share of patients with complex social and medical needs
Summary
The Medicare program is increasingly focusing on value-based payments to reduce costs and improve quality of care. Value-based payments may differentially affect hospitals serving a high percentage of patients with low socioeconomic status or medical complexity.[1,2,3] Patients with social and medical complexity may have needs that are insufficiently measured through traditional risk adjustment, affecting a hospital’s performance on spending and quality measures of value-based payment programs. These concerns may be salient when considering the influence of mandatory value-based payment models on hospitals serving a high percentage of disadvantaged patients. If spending is below benchmark and hospitals meet the quality threshold, they receive a bonus.[4]
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