Care For Joint Replacement Research Articles

Penalties and Rewards for Safety Net vs Non–Safety Net Hospitals in the First 2 Years of the Comprehensive Care for Joint Replacement Model

This study compared monetary penalties and rewards among safety net vs non–safety net hospitals under Medicare’s Comprehensive Care for Joint Replacement (CJR) model, a bundled payment plan for hip and knee replacements intended to incentivize health care quality and savings, in 2016 and 2017.

No Changes in Patient Selection and Value-Based Metrics for Total Hip Arthroplasty After Comprehensive Care for Joint Replacement Bundle Implementation at a Single Center

BackgroundAlternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services to decrease overall healthcare cost. The associated shift of financial risk to participating institutions may negatively influence patient selection to avoid high cost of care (“cherry picking,” “lemon dropping”). This study evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery, and hospital costs at a single care center. MethodsPatients undergoing a primary THA from 2015-2017 were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before (pre-CJR) or after (post-CJR) CJR bundle implementation. Patient age, gender, and body mass index, Elixhauser comorbidities and American Society of Anesthesiologists scores, were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared pre- and post-CJR. ResultsA total of 751 THA patients (273 Medicare and 478 commercial Insurance) were evaluated pre-CJR (29%) and post-CJR (71%). Patient demographics were similar (age, gender, BMI); however, commercially insured patients had less comorbidities pre-CJR (P = .033). Medicare patient post-CJR length of stay (P = .010) was reduced with a trend toward discharge to home (P = .019). Surgical time, operating room service time, 90-day readmissions and direct hospital costs were similar pre- and post-CJR. ConclusionThere was no differential patient selection after CJR bundle implementation and value-based metrics (surgical time, operating room service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals.

Value-Based Care Has Not Resulted in Biased Patient Selection: Analysis of a Single Center’s Experience in the Care for Joint Replacement Bundle

BackgroundBundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center. MethodsThis is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care. ResultsA total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P < .001), prolonged length of stay (P < .001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients. ConclusionImplementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.

Quality Measures in Total Hip and Total Knee Arthroplasty.

Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures. This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search. We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%). Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement. Level I, systematic review of level I evidence.

Alternative Payment Models in Total Joint Arthroplasty Under the Affordable Care Act.

» Since the passage of the U.S. Patient Protection and Affordable Care Act (ACA), health care has transitioned from a volume-based enterprise to a quality-based enterprise. Under this legislation, Alternative Payment Models (Bundled Payments for Care Improvement [BPCI], Comprehensive Care for Joint Replacement [CJR], and Accountable Care Organizations [ACOs]) have been developed to provide stakeholders with reimbursement systems that reward high-quality care and cost reduction.» The goal of this article was to elaborate on the various Alternative Payment Models and recent amendments and how these unique payment paradigms may offer orthopaedic surgeons innovative principles to further advance the quality and efficiency of total joint arthroplasty.

Performance Of Safety-Net Hospitals In Year 1 Of The Comprehensive Care For Joint Replacement Model.

The Comprehensive Care for Joint Replacement (CJR) model of 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study, we used Medicare’s CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals’ rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend might place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients might enable safety-net hospitals to compete effectively in CJR.

Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement

BackgroundIn 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge).MethodsWe conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as “treatment” areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post–acute care facilities), rates of postsurgical complications, and the percentage of “high-risk” patients (i.e., patients for whom there was an elevated risk of spending — a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures.ResultsFrom 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], −$812, or a −3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post–acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81).ConclusionsIn the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.)

National Representativeness Of Hospitals And Markets In Medicare's Mandatory Bundled Payment Program.

In 2016 Medicare implemented its first mandatory alternative payment model, the Comprehensive Care for Joint Replacement (CJR) program, in which the agency pays clinicians and hospitals a fixed amount for services provided in hip and knee replacement surgery episodes. Medicare made CJR mandatory, rather than voluntary, to produce generalizable evidence on what results Medicare might expect if it scaled bundled payment up nationally. However, it is unknown how markets and hospitals in CJR compare to others nationwide, particularly with respect to baseline quality and spending performance and the structural hospital characteristics associated with early savings in CJR. Using data from Medicare, the American Hospital Association, and the Health Resources and Services Administration, we found differences in structural market and hospital characteristics but largely similar baseline hospital episode quality and spending. Our findings suggest that despite heterogeneity in hospital characteristics associated with early savings in CJR, Medicare might nonetheless reasonably expect similar results by scaling CJR up to additional urban markets and increasing total program coverage to areas in which 71percent of its beneficiaries reside. In contrast, different policy designs may be needed to extend market-level programs to other regions or enable different hospital types to achieve savings from bundled payment reimbursement.

Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased Hospital Returns for Total Knee Arthroplasty

BackgroundThe Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks. We hypothesized that this checklist would improve postoperative metrics that impact costs for total knee arthroplasty (TKA) patients eligible for participation in CJR. MethodsPatients undergoing TKA from 2014 to 2018 were retrospectively reviewed. Only patients with eligible participation in CJR were included. Outcome variables including length of stay, disposition, 90-day emergency department visits, and hospital readmissions were explored. Analysis was performed to determine differences in outcomes between CJR participating and non-CJR participating hospitals within the healthcare system. ResultsIn total, 2308 TKA patients including 1564 from a CJR participating center and 744 from a non-CJR center were analyzed. There was no significant difference in patient age or gender. Patients at the non-CJR hospital had significantly higher body mass index (P < .001) and American Society of Anesthesiologists scores (P < .001), while those in the CJR network had fewer skilled nursing facility discharges (P = .028) and shorter length of stay (P < .001). However, there was no reduction in 90-day emergency department visits or readmissions. ConclusionThe resources utilized at CJR participating hospitals, including patient optimization checklists, did not effectively alter patient outcomes following discharge. Likely, a checklist alone is insufficient for risk mitigation and detailed optimization protocols for modifiable risk factors must be investigated.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery

BackgroundComprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. MethodsSeventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. ResultsSurgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. ConclusionParticipation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.

The University of Missouri Health Care approach to Comprehensive Care for Joint Replacement.

The University of Missouri Health Care is a 5-hospital academic medical center with 595 beds, located in the central United States. Our system was selected for mandatory participation in the Comprehensive Care for Joint Replacement bundled payment model and participated from April 2016 through December 2017. Using an established improvement model, we implemented several key strategies which resulted in improved quality and lower overall costs.

Identifying high-cost episodes in lower extremity joint replacement.

To evaluate the ability of claims-based risk adjustment and incremental components of clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions. Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups. Multivariable logistic models identified high-cost episodes. Clinical data from participating health care systems merged with Medicare FFS data. Our three populations consisted of 363621 patients in the CMS population, 4881 in the HVHC population, and 918 in the Mayo population. When modeling per CJR specifications, we observed low to moderate model performance (CMS C-Stat=0.714; HVHC C-Stat=0.628; Mayo C-Stat=0.587). Adding CMS-HCC categories improved identification of patients in the top 20% of episode costs (CMS C-Stat=0.758, HVHC C-Stat=0.692, Mayo C-Stat=0.677). Clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat=0.783), improved ability to identify patients within cost groups. Policy makers could use these findings to improve payment adjustments for bundled LEJR procedures and in consideration of new data elements for reimbursement.

Characteristics of Hospitals Exiting the Newly Voluntary Comprehensive Care for Joint Replacement Program

In 2018, Medicare made participation in the Comprehensive Care for Joint Replacement (CJR) program, which had been mandatory for all hospitals in 67 metropolitan statistical areas (MSAs), voluntary in the 33 of 67 MSAs with the lowest historical costs. CJR was designed to hold hospitals accountable for the cost and quality of care during hip or knee replacement episodes, defined as hospitalization and 90 days of post-discharge care. We compared hospitals that stayed with the CJR program against those that withdrew. This information is important for understanding the effects of voluntary payment models.

Possible Implications for Bundled Payment Models of Comorbidities and Complications as Drivers of Cost in Total Ankle Arthroplasty.

The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital and 90-day postdischarge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help identify modifiable preoperative patient factors that could be addressed prior to the patient entering the bundle, as well as determine targets for cost reduction in postoperative care. This study is part of an institutional review board-approved single-center observational study of patients undergoing TAA from January 1, 2012, to December 15, 2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model. All Medicare payments beginning at the index procedure through 90 days postoperatively were identified. Patient, operative, and postoperative characteristics were associated with costs in adjusted, multivariable analyses. One hundred thirty-seven patients met inclusion criteria for the study. Cerebrovascular disease (intracranial hemorrhages, strokes, or transient ischemic attacks) was initially associated with increased costs (mean, $5595.25; 95% CI, $1710.22-$9480.28) in adjusted analyses ( P = .005), though this variable did not meet a significance threshold adjusted for multiple comparisons. Increased length of stay, discharge to a skilled nursing facility (SNF), admissions, emergency department (ED) visits, and wound complications were significant postoperative drivers of payment. Common comorbidities did not reliably predict increased costs. Increased length of stay, discharge to an SNF, readmission, ED visits, and wound complications were postoperative factors that considerably increased costs. Lastly, reducing the rates of SNF placement, readmission, ED visitation, and wound complications are targets for reducing costs for patients undergoing TAA. Level II, prognostic prospective cohort study.

Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care

Bundled payments are an increasingly common alternative payment model for Medicare, yet there is limited evidence regarding their effectiveness. To report interim outcomes from the first year of implementation of a bundled payment model for lower extremity joint replacement (LEJR). As part of a 5-year, mandatory-participation randomized trial by the Centers for Medicare & Medicaid Services, eligible metropolitan statistical areas (MSAs) were randomized to the Comprehensive Care for Joint Replacement (CJR) bundled payment model for LEJR episodes or to a control group. In the first performance year, hospitals received bonus payments if Medicare spending for LEJR episodes was below the target price and hospitals met quality standards. This interim analysis reports first-year data on LEJR episodes starting April 1, 2016, with data collection through December 31, 2016. Randomization of MSAs into the CJR bundled payment model group (75 assigned; 67 included) or to the control group without the CJR model (121 assigned; 121 included). Instrumental variable analysis was used to evaluate the relationship between inclusion of MSAs in the CJR model and outcomes. The primary outcome was share of LEJR admissions discharged to institutional postacute care. Secondary outcomes included the number of days in institutional postacute care, discharges to other locations, Medicare spending during the episode (overall and for institutional postacute care), net Medicare spending during the episode, LEJR patient volume and patient case mix, and quality-of-care measures. Among the 196 MSAs and 1633 hospitals, 131 285 eligible LEJR procedures were performed during the study period (mean volume, 110 LEJR episodes per hospital) among 130 343 patients (mean age, 72.5 [SD, 0.91] years; 65% women; 90% white). The mean percentage of LEJR admissions discharged to institutional postacute care was 33.7% (SD, 11.2%) in the control group and was 2.9 percentage points lower (95% CI, -4.95 to -0.90 percentage points) in the CJR group. Mean Medicare spending for institutional postacute care per LEJR episode was $3871 (SD, $1394) in the control group and was $307 lower (95% CI, -$587 to -$27) in the CJR group. Mean overall Medicare spending per LEJR episode was $22 872 (SD, $3619) in the control group and was $453 lower (95% CI, -$909 to $3) in the CJR group, a statistically nonsignificant difference. None of the other secondary outcomes differed significantly between groups. In this interim analysis of the first year of the CJR bundled payment model for LEJR among Medicare beneficiaries, MSAs covered by CJR, compared with those that were not, had a significantly lower percentage of discharges to institutional postacute care but no significant difference in total Medicare spending per LEJR episode. Further evaluation is needed as the program is more fully implemented. ClinicalTrials.gov Identifier: NCT03407885; American Economic Association Registry Identifier: AEARCTR-0002521.

Patient Risk Factors Do Not Impact 90-Day Readmission and Emergency Department Visitation After Total Ankle Arthroplasty: Implications for the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Plan.

The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital care and care within 90 days following discharge for Medicare beneficiaries undergoing lower-extremity joint replacement involving the hip, knee, or ankle (total hip arthroplasty, total knee arthroplasty, or total ankle arthroplasty [TAA]). The study hypothesis was that patient comorbidities are associated with readmissions, emergency department (ED) utilization, and subspecialist wound-healing consultation, which are examples of costly contributors to postoperative health-care spending. The medical records for 1,024 patients undergoing TAAs between June 2007 and December 2016 at a single academic center in the southeastern United States were reviewed for the outcomes of readmissions, ED visitations, and subspecialist wound-healing consultation within the 90-day post-discharge period. All patients undergoing TAA (n = 1,365) were eligible. Of the 1,037 patients who consented to participation in the study and underwent TAA, 1,024 (98.7%) completed the study. Medical comorbidities according to the Elixhauser and Charlson-Deyo comorbidity indices that were present prior to TAA were recorded. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. Four hundred and ninety-six (48.4%) of the 1,024 patients were female, and 964 (94.1%) were white/Caucasian, with an average age (and standard deviation) of 63 ± 10.5 years. Hypertension, obesity, solid tumor, depression, rheumatic disease, cardiac arrhythmia, hypothyroidism, diabetes mellitus, and chronic pulmonary disease had a prevalence of >10%. Fifty-three (5.2%) of the 1,024 patients were readmitted for any cause. Thirty-six (3.5%) of the 1,024 returned to the ED but were not admitted to the hospital. Readmission or ED visitation was most commonly for a wound complication, followed by deep venous thrombosis (DVT) and pulmonary embolism (PE) evaluation, while urgent medical evaluations composed the majority of non-TAA-related ED visitations. No patient comorbidities were significantly associated with 90-day readmission, ED visitation, or wound complications in multivariable models. Patient comorbidities were not associated with 90-day hospital readmissions or ED visitation for patients undergoing TAA. Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. These data suggest that there may be considerable differences between TAA and total hip arthroplasty or total knee arthroplasty that cause surgeons to question the inclusion of TAA in CJR bundled payment models. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroplasty or Arthrodesis in the CJR Era

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis can be a debilitating disease that results in decreased daily activity and chronic morbidity. Many patients elect for surgical intervention to minimize pain and improve function. To curb costs associated with the increasing demand for total joint arthroplasty (TJA) in the growing elderly Medicare population, CMS announced the Comprehensive Care for Joint Replacement (CJR) model, which included total ankle arthroplasty. To provide continued quality care and cost containment, it is necessary to determine the optimal surgical intervention for patients that could fall within the CJR program. Therefore, we sought to determine the impact of surgical fixation on functional outcomes, systemic utilization, and medical expenditures for patients with ankle arthritis. Methods: We reviewed a prospectively collected and maintained database to identify all patients who underwent a total joint replacement from April 2016 to September 2017. Patients were identified based on DRG codes for primary arthritis of a lower extremity joint, then specifically for foot and ankle, as well as CPT codes for ankle arthroplasty (27702) or ankle arthrodesis (27870/28725). Functional outcomes were assessed based on insurance type. The cohorts were matched for age, comorbidities, and gender. Statistical analysis was performed using chi-squared and paired t-test to assess for differences in patient reported outcomes. Descriptive statistical analysis was used to assess for differences in cost between the cohorts. Results: A total of 573 patients were included.There were 48 replacements and 47 fusions. Arthrodesis procedures costs approximately $6,500 less per case than the system costs for patients who underwent arthroplasty procedures. The average length of stay for patients who underwent total ankle arthroplasty was 1.6 days compared to outpatient surgical centers utilized for most arthrodesis patients. Overall, patients reported improved pain and a 30.96 increase in FAAM scores. Most patients had a global rate of change that was “very much better” or “much better” (68%). Based on insurance type, patients who underwent a total ankle replacement in the CJR program had improved outcomes and lower cost than patients commercially insured. Conclusion: With the CJR, there is greater emphasis on the optimal intervention for elective operations. There should be coordinated efforts to optimize quality care, while minimizing financial waste within the healthcare system. The price differential suggests an annual potential for financial savings as high as $325,000 for a system that supports intervention for ~50 cases per year. As such, these results suggest that arthroplasty may be optimal for patients with severe symptomatic ankle arthritis, while most patients have adequate relief with an ankle fusion. More importantly, quality improvement efforts should focus on the impact of surgical intervention on functional activity.

The Effects of Revision Total Hip Arthroplasty on Medicare Spending and Beneficiary Outcomes: Implications for the Comprehensive Care for Joint Replacement Model

BackgroundAfter the first year in the Comprehensive Care for Joint Replacement (CJR) model, hospitals must repay Medicare for spending above a target price. Hospitals are incentivized to reduce spending in a 90-day episode and generate internal cost savings through, for example, the use of lower-cost implants. MethodsWe used a Markov model to compare quality-adjusted life-years and lifetime costs of total hip arthroplasty, under Medicare fee-for-service (baseline) and under alternative revision rate assumptions (prospective CJR scenarios). Results were generated for 65-year-old and 75-year-old male and female Medicare beneficiaries using baseline spending and revision rates from Medicare claims. We estimated the impact of CJR on 90-day spending. We ran sensitivity analyses for revision rates. ResultsUnder willingness-to-pay thresholds of $50,000, $100,000, and $150,000, the baseline scenario was more cost-effective than the CJR scenario for a 65-year-old male patient if the revision risk increases by at least 7% (95% confidence interval for CJR savings: 4%-22%), 5% (range, 3%-7%), or 3% (range, 1%-5%), respectively. For males aged 75 years and females, revision risk needs to increase by a greater percentage under CJR relative to baseline for Medicare fee-for-service to be more cost-effective. ConclusionThe CJR model holds great promise. However, it incentivizes hospitals to choose lower-cost implants and adopt newer technology more slowly, which could potentially increase revision rates and offset benefits of the program. Policy makers should monitor revision rates and consider changes to the CJR model to ensure beneficiary access to valuable technology.

Are Medicare's “Comprehensive Care for Joint Replacement” Bundled Payments Stratifying Risk Adequately?

BackgroundBundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program. MethodsNinety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period. ResultsAverage reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R2 = 0.23 vs 0.17). ConclusionMore robust risk stratification could provide more equitable reimbursement in the CJR program. Level of EvidenceLarge database analysis; Level III.

Preoperative Patient Profile in Total Hip and Knee Arthroplasty: Predictive of Increased Medicare Payments in a Bundled Payment Model

BackgroundThe shift toward value-based bundled payment models in total joint arthroplasty highlights the need for identification of modifiable risk factors for increased spending as well as opportunities to mitigate perioperative treatment of chronic disease. The purpose of this study was to identify preoperative comorbidities that result in an increased financial burden using institutional data at a single institution. MethodsWe conducted a retrospective review of total joint arthroplasty patients and collected payment data from the Center for Medicare and Medicaid Services for each patient up to 90 days after surgery in accordance with the regulations of the Comprehensive Care for Joint Replacement initiative. Statistical analysis and comparison of preoperative profile and Medicare payments as a surrogate for cost were completed. ResultsSix hundred ninety-four patients were identified over a 4-year time period who underwent surgery before adoption of the Comprehensive Care for Joint Replacement but that met criteria for inclusion. The median total payment per patient episode of care was $20,048. Preoperative diagnosis of alcoholism, anemia, diabetes, and obesity was found to have a statistically significant effect on total payments. The model predicted a geometric mean increase from $1425 to $9308 for patients bearing these comorbidities. ConclusionWith Medicare payments as a surrogate for cost, we demonstrate that specific patient comorbidities and a cumulative increase in comorbidities predict increased costs. This study was based on institutional data rather than administrative data to gain actionable information on an institutional level and highlight potential flaws in research based on administrative data.