1
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Kilaru AS, Liao JM, Wang E, Zhao Y, Zhu J, Ng G, Shirk T, Cousins DS, Kanter GP, Ibrahim S, Navathe AS. Association between mandatory bundled payments and changes in socioeconomic disparities for joint replacement outcomes. Health Serv Res 2024; 59:e14369. [PMID: 39128893 PMCID: PMC11366957 DOI: 10.1111/1475-6773.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
OBJECTIVE To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid. DATA SOURCES AND STUDY SETTING We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017. STUDY DESIGN We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program. The primary outcome was LEJR complications. Secondary outcomes included 90-day readmissions and mortality. DATA EXTRACTION METHODS We identified hospitals in the US market areas eligible for CJR. We included beneficiaries in the intervention group who received joint replacement at hospitals in markets randomized to participate in CJR. The comparison group included patients who received joint replacement at hospitals in markets who were eligible for CJR but randomized to control. PRINCIPAL FINDINGS The study included 1,603,555 Medicare beneficiaries (mean age, 74.6 years, 64.3% women, 11.0% dual-eligible). Among participant hospitals, complications decreased between baseline and intervention periods from 11.0% to 10.1% for dual-eligible and 7.0% to 6.4% for non-dual-eligible beneficiaries. Among nonparticipant hospitals, complications decreased from 10.3% to 9.8% for dual-eligible and 6.7% to 6.0% for non-dual-eligible beneficiaries. In adjusted analysis, CJR participation was associated with a reduced difference in complications between dual-eligible and non-dual-eligible beneficiaries (-0.9 percentage points, 95% CI -1.6 to -0.1). The reduction in disparities was observed among hospitals without prior experience in a voluntary LEJR bundled payment model. There were no differential changes in 90-day readmissions or mortality. CONCLUSIONS Mandatory participation in a bundled payment program was associated with reduced disparities in joint replacement complications for Medicare beneficiaries with low income. To our knowledge, this is the first evidence of reduced socioeconomic disparities in outcomes under value-based payments.
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MESH Headings
- Humans
- United States
- Female
- Male
- Aged
- Retrospective Studies
- Medicare/statistics & numerical data
- Medicare/economics
- Socioeconomic Factors
- Healthcare Disparities/statistics & numerical data
- Patient Care Bundles/economics
- Arthroplasty, Replacement/economics
- Arthroplasty, Replacement/statistics & numerical data
- Patient Readmission/statistics & numerical data
- Aged, 80 and over
- Medicaid/statistics & numerical data
- Medicaid/economics
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Socioeconomic Disparities in Health
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Affiliation(s)
- Austin S. Kilaru
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Joshua M. Liao
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal Medicine, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Erkuan Wang
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yueming Zhao
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jingsan Zhu
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Grace Ng
- Department of NeurosurgeryMassachusetts General HospitalBostonMassachusettsUSA
| | - Torrey Shirk
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Deborah S. Cousins
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Genevieve P. Kanter
- Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Said Ibrahim
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Amol S. Navathe
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of MedicineCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA
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2
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Templeton KJ. CORR Insights®: Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital? Clin Orthop Relat Res 2024; 482:1452-1454. [PMID: 38917080 PMCID: PMC11272355 DOI: 10.1097/corr.0000000000003158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024]
Affiliation(s)
- Kimberly J Templeton
- Professor, Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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3
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Shashikumar SA, Ryan AM, Joynt Maddox KE. Equity Implications of Hospital Penalties During 4 Years of the Comprehensive Care for Joint Replacement Model, 2016 to 2019. JAMA HEALTH FORUM 2022; 3:e224455. [PMID: 36459162 PMCID: PMC9719045 DOI: 10.1001/jamahealthforum.2022.4455] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This cross-sectional study assesses the penalties against hospitals under the Comprehensive Care for Joint Replacement model mandated by Medicare, with particular attention to safety-net hospitals and those serving a high proportion of Black or Hispanic patients.
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Affiliation(s)
- Sukruth A. Shashikumar
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Andrew M. Ryan
- School of Public Health, Brown University, Providence, Rhode Island
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri,Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
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4
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Profound Impact of Insurance Payor and Socioeconomic Status in Total Hip Arthroplasty Outcomes: Results From a High Volume Tertiary Care Center. J Arthroplasty 2022; 37:S434-S438. [PMID: 35278670 DOI: 10.1016/j.arth.2022.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/24/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Dual eligible Medicare/Medicaid patients undergoing total hip arthroplasty (THA) have worse outcomes compared to other insurance payors. Prior literature fails to control for the heterogeneity of care provided amongst a large cohort of hospitals and surgeons as well as differences in patient populations treated. This study compares dual eligible THA patients and Medicaid and Medicare only THA patients at a single high volume tertiary center. METHODS We retrospectively reviewed patients who underwent THA for aseptic osteoarthritis of the hip over a three-year period with either Medicaid or Medicare insurance. 3,329 THA patients were included, of which 439 were Medicaid payor, 182 were dual eligible, and 2,708 were Medicare payor. Groups were compared using appropriate tests for direct comparisons and regression analysis. RESULTS Dual eligible patients were less likely to be white and married, and were more likely to be current smokers and have COPD, liver disease, renal disease, and human immunodeficiency virus (HIV) compared to Medicare patients. These patients also had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients (2.4 vs 3.4, P < .001). When controlling for smoking status, age, BMI and major medical comorbidities, dual eligible and Medicaid patients had increased length of stay (LOS) (0.58, 0.66 days, P < .001), higher risk of discharge to subacute rehabilitation (RR 1.97, 3.19, P < .001), and dual eligible patients more often returned to the ED within 90 days (RR 2.74, P < .001) compared to Medicare patients. CONCLUSION This study supports the implementation of socioeconomic risk stratification efforts to properly evaluate value-based healthcare metrics in total hip arthroplasty patients.
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Chan AK, Shahrestani S, Ballatori AM, Orrico KO, Manley GT, Tarapore PE, Huang M, Dhall SS, Chou D, Mummaneni PV, DiGiorgio AM. Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery? Neurosurgery 2022; 91:123-131. [PMID: 35550453 PMCID: PMC9514755 DOI: 10.1227/neu.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery. OBJECTIVE To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery. METHODS The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization. RESULTS We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score. CONCLUSION The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.
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Affiliation(s)
- Andrew K. Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Shane Shahrestani
- Department of Medical Engineering, California Institute of Technology, Pasadena, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander M. Ballatori
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Katie O. Orrico
- American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Office, Washington, District of Columbia, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Michael Huang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sanjay S. Dhall
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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6
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Koressel JE, Perez BA, Kerbel YE, DeAngelis RD, Israelite CL, Nelson CL. Does Dual-Eligible Medicare/Medicaid Insurance Status as a Surrogate for Socioeconomic Status Compromise Total Knee Arthroplasty Outcomes? J Arthroplasty 2022; 37:S32-S36. [PMID: 35190241 DOI: 10.1016/j.arth.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Medicare/Medicaid dual-eligible patients who undergo primary total knee arthroplasty (TKA) demonstrate poor outcomes when compared to patients with other payers. We compare Medicare/Medicaid dual-eligible patients vs Medicare and Medicaid only patients at a single hospital center. METHODS All patients who underwent TKA for aseptic arthritis between August 9, 2016 and December 30, 2020 with either Medicare or Medicaid insurance were retrospectively reviewed. 4599 consecutive TKA (3749 Medicare, 286 Medicare/Medicaid dual eligibility, and 564 Medicaid) were included. Groups were compared using appropriate tests for direct comparisons and regression analysis. RESULTS Patients with dual eligibility and Medicaid insurance were less likely to be white and married, more likely to be female and current smokers, and more likely to have COPD, mild liver disease, diabetes mellitus, malignancy, and HIV/AIDS, but had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients. When controlling for smoking status and medical comorbidities, patients with dual eligibility and Medicaid insurance stayed in the hospital 0.64 and 0.39 additional days (P < .001), respectively, were more likely to be discharged to subacute rehab (RR 2.01, 1.49, P < .001) and acute rehab (RR 2.22, 2.46, P = .007, < .001), and were 2.14 and 1.73 times more likely to return to the ED within 90 days (P < .001) compared to Medicare patients. CONCLUSION Value-based healthcare may disincentivize treating patients with low socioeconomic status, represented by Medicaid and dual-eligible insurance status, by their association with increased postoperative healthcare utilization, and less risky patients may be prioritized.
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Affiliation(s)
- Joseph E Koressel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Brian A Perez
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Yehuda E Kerbel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Ryan D DeAngelis
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Craig L Israelite
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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7
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Galivanche AR. CORR Insights®: How Should We Measure Social Deprivation in Orthopaedic Patients? Clin Orthop Relat Res 2022; 480:340-342. [PMID: 34939943 PMCID: PMC8747505 DOI: 10.1097/corr.0000000000002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Anoop Raj Galivanche
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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8
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Liao JM, Chatterjee P, Wang E, Connolly J, Zhu J, Cousins DS, Navathe AS. The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes. J Hosp Med 2021; 16:716-723. [PMID: 34798000 PMCID: PMC8626055 DOI: 10.12788/jhm.3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Under Medicare's Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges. OBJECTIVE To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes. DESIGN, SETTING, AND PARTICIPANTS This observational difference-in-differences analysis was conducted in safety net and non-safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. EXPOSURE(S) Hospital BPCI participation and safety net status. MAIN OUTCOME(S) AND MEASURE(S) The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures. RESULTS Our sample consisted of 803 safety net and 2263 non-safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non-safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, -$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post-acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, -1.15 percentage points; 95% CI, -1.73 to -0.58; P < .001) than BPCI non-safety net hospitals. CONCLUSIONS Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post-acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corresponding Author: Joshua M Liao, MD, MSc; ; Telephone: 206-616-6934. Twitter: @JoshuaLiaoMD
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Connolly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah S Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
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9
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022] Open
Abstract
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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10
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Li Y, Ying M, Cai X, Thirukumaran CP. Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients. Med Care 2021; 59:101-110. [PMID: 33273296 PMCID: PMC7855778 DOI: 10.1097/mlr.0000000000001473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Orthopaedics, University of Rochester Medical Center
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11
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Thirukumaran CP, Cai X, Glance LG, Kim Y, Ricciardi BF, Fiscella KA, Li Y. Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017. J Bone Joint Surg Am 2020; 102:2120-2128. [PMID: 33079898 PMCID: PMC8190867 DOI: 10.2106/jbjs.20.00246] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.
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Affiliation(s)
- Caroline P Thirukumaran
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Xueya Cai
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Laurent G Glance
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Benjamin F Ricciardi
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kevin A Fiscella
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Yue Li
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
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12
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Reply to Letter to the Editor: Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure. J Am Acad Orthop Surg 2020; 28:e877. [PMID: 31855589 DOI: 10.5435/jaaos-d-19-00803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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13
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Kim H, Meath THA, Tran FW, Quiñones AR, McConnell KJ, Ibrahim SA. Association of Medicare Mandatory Bundled Payment System for Hip and Knee Joint Replacement With Racial/Ethnic Difference in Joint Replacement Care. JAMA Netw Open 2020; 3:e2014475. [PMID: 32960277 PMCID: PMC7509636 DOI: 10.1001/jamanetworkopen.2020.14475] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023] Open
Abstract
Importance There are marked racial/ethnic differences in hip and knee joint replacement care as well as concerns that value-based payments may exacerbate existing racial/ethnic disparities in care. Objective To examine changes in joint replacement care associated with Medicare's Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients. Design, Setting, and Participants Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic patients undergoing joint replacement in 67 treatment (selected for CJR participation) and 103 control metropolitan statistical areas. Exposures The CJR model holds hospitals accountable for spending and quality of joint replacement care during care episodes (index hospitalization through 90 days after discharge). Main Outcomes and Measures The primary outcomes were spending, discharge to institutional postacute care, and readmission during care episodes. Results Among 688 346 patients, 442 163 (64.2%) were women, and 87 286 (12.7%) were 85 years or older. Under CJR, spending decreased by $439 for White patients (95% CI, -$718 to -$161; from pre-CJR spending in treatment metropolitan statistical areas of $25 264) but did not change for Black patients and Hispanic patients. Discharges to institutional postacute care decreased for all groups (-2.5 percentage points; 95% CI, -4.7 to -0.4, from pre-CJR risk of 46.2% for White patients; -6.0 percentage points; 95% CI, -9.8 to -2.2, from pre-CJR risk of 59.5% for Black patients; and -4.3 percentage points; 95% CI, -7.6 to -1.0, from pre-CJR risk of 54.3% for Hispanic patients). Readmission risk decreased for Black patients by 3.1 percentage points (95% CI, -5.9 to -0.4, from pre-CJR risk of 21.8%) and did not change for White patients and Hispanic patients. Under CJR, Black-White differences in discharges to institutional postacute care decreased by 3.4 percentage points (95% CI, -6.4 to -0.5, from the pre-CJR Black-White difference of 13.3 percentage points). No evidence was found demonstrating that Black-White differences changed for other outcomes or that Hispanic-White differences changed for any outcomes under CJR. Conclusions and Relevance In this cohort study of patients receiving joint replacements, CJR was associated with decreased readmissions for Black patients. Furthermore, Black patients experienced a greater decrease in discharges to institutional postacute care relative to White patients, representing relative improvements despite concerns that value-based payment models may exacerbate existing disparities. Nonetheless, differences between White and Black patients in joint replacement care still persisted even after these changes.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Thomas H. A. Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Felix W. Tran
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Ana R. Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Said A. Ibrahim
- Department of Population Health Sciences, Weill Cornell Medicine/New York Presbyterian Health System, New York, New York
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Kim H, Meath THA, Dobbertin K, Quiñones AR, Ibrahim SA, McConnell KJ. Association of the Mandatory Medicare Bundled Payment With Joint Replacement Outcomes in Hospitals With Disadvantaged Patients. JAMA Netw Open 2019; 2:e1914696. [PMID: 31693127 PMCID: PMC6865278 DOI: 10.1001/jamanetworkopen.2019.14696] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/16/2019] [Indexed: 11/21/2022] Open
Abstract
Importance 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). Objective To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. Design, Setting, and Participants 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. Exposures 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. Main Outcomes and Measures 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. Results 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. Conclusions and Relevance 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.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Thomas H. A. Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Konrad Dobbertin
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Ana R. Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Said A. Ibrahim
- Department of Healthcare Policy and Research, Weill Cornell Medicine/New York-Presbyterian, New York, New York
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Humbyrd CJ. CORR Insights®: What is the Impact of Social Deprivation on Physical and Mental Health in Orthopaedic Patients? Clin Orthop Relat Res 2019; 477:1836-1838. [PMID: 31335601 PMCID: PMC7000008 DOI: 10.1097/corr.0000000000000893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 06/24/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Casey J Humbyrd
- C. J. Humbyrd, Chief, Foot and Ankle Division, Assistant Professor of Orthopaedic Surgery, The Johns Hopkins Medicine, Baltimore, MD, USA
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