1
|
Kim H, Hart KD, Senders A, Schabel K, Ibrahim SA. Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups. Popul Health Manag 2024; 27:128-136. [PMID: 38442304 DOI: 10.1089/pop.2023.0310] [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] [Indexed: 03/07/2024] Open
Abstract
Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.
Collapse
Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle D Hart
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela Senders
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn Schabel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Said A Ibrahim
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, USA
| |
Collapse
|
2
|
Warren SI, Pham NS, Foreman CW, Huddleston JI. Concentrated Economic Disadvantage Predicts Resource Utilization After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2526-2530.e1. [PMID: 37595766 DOI: 10.1016/j.arth.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND The Index of Concentration at the Extremes (ICE), a measure of geographic socioeconomic polarization, predicts several health outcomes but has not been evaluated concerning total knee arthroplasty (TKA). This study evaluates ICE as a predictor of post-TKA resource utilization. METHODS Using the Healthcare Cost and Utilization Project's New York State database from 2016 to 2017, we retrospectively evaluated 57,426 patients ≥50 years undergoing primary TKA. The ICE values for extreme concentrations of income and race were calculated using United States Census Bureau data with the formula ICEi = (Pi-Di)/Ti where Pi, Di, and Ti are the number of households in the most privileged extreme, disadvantaged extreme, and total population in zip code i, respectively. Extremes of privilege and disadvantage were defined as ≥$150,000 versus <$25,000 for income and non-Hispanic White versus non-Hispanic Black for race. Association of ICE values, demographics, and comorbidities with 90-day readmission and 90-day emergency department (ED) visits was examined using multivariable analysis. RESULTS Overall 90-day readmission and ED visit rates were 12.8% and 9.4%, respectively. On multivariable analysis, the lowest ICEIncome quintile (concentrated poverty) predicted 90-day readmission (odds ratio 1.17, 95% confidence interval 1.05 to 1.30, P = .005) and 90-day ED visit (odds ratio 1.22, 95% confidence interval 1.08 to 1.38, P = .001). The ICERace was not predictive of either outcome. CONCLUSION Patients in communities with the lowest ICEIncome values use more inpatient and ED resources after primary TKA. Incorporating ICEIncome into risk-adjusted payment models may help align incentives for equitable care.
Collapse
Affiliation(s)
- Shay I Warren
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Nicole S Pham
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Cameron W Foreman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| |
Collapse
|
3
|
Kidanemariam M, Pieterse AH, van Staalduinen DJ, Bos WJW, Stiggelbout AM. Does value-based healthcare support patient-centred care? A scoping review of the evidence. BMJ Open 2023; 13:e070193. [PMID: 37429675 DOI: 10.1136/bmjopen-2022-070193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Standardisation of outcome measures is integral to value-based healthcare (VBHC), which may conflict with patient-centred care, focusing on personalisation. OBJECTIVES We aimed to provide an overview of measures used to assess the effect of VBHC implementation and to examine to what extent the evidence indicates that VBHC supports patient-centred care. DESIGN A scoping review guided by the Joanna Briggs Institute methodology. SOURCES OF EVIDENCE We searched the following databases on 18 February 2021: Cochrane Library, EMBASE, MEDLINE and Web of Science. ELIGIBILITY CRITERIA We included empirical papers assessing the effect of the implementation of VBHC, published after introduction of VBHC in 2006. DATA EXTRACTION AND SYNTHESIS Two independent reviewers double-screened papers and data were extracted by one reviewer and checked by the other. We classified the study measures used in included papers into six categories: process indicator, cost measure, clinical outcome, patient-reported outcome, patient-reported experience or clinician-reported experience. We then assessed the patient-centredness of the study measures used. RESULTS We included 39 studies using 94 unique study measures. The most frequently used study measures (n=72) were process indicators, cost measures and clinical outcomes, which rarely were patient-centred. The less frequently used (n=20) patient-reported outcome and experience measures often measured a dimension of patient-centred care. CONCLUSION Our study shows that the evidence on VBHC supporting patient-centred care is limited, exposing a knowledge gap in VBHC research. The most frequently used study measures in VBHC research are not patient-centred. The major focus seems to be on measures of quality of care defined from a provider, institution or payer perspective.
Collapse
Affiliation(s)
- Martha Kidanemariam
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Arwen H Pieterse
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorine J van Staalduinen
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
- Institute of Public Administration, Leiden University, The Hague, The Netherlands
| | - Willem Jan W Bos
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Anne M Stiggelbout
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
4
|
KADAKIA KUSHALT, OFFODILE ANAEZEC. The Next Generation of Payment Reforms for Population Health - An Actionable Agenda for 2035 Informed by Past Gains and Ongoing Lessons. Milbank Q 2023; 101:866-892. [PMID: 37096610 PMCID: PMC10126963 DOI: 10.1111/1468-0009.12632] [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: 04/15/2022] [Revised: 09/13/2022] [Accepted: 01/06/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points The predominantly fee-for-service reimbursement architecture of the US health care system contributes to waste and excess spending. While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population-based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity. To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value-based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross-sector entities to invest in the upstream drivers of health.
Collapse
Affiliation(s)
| | - ANAEZE C. OFFODILE
- University of Texas MD Anderson Cancer Center and Baker Institute for Public Policy, Rice University
| |
Collapse
|
5
|
Powers BW, Figueroa JF, Canterberry M, Gondi S, Franklin SM, Shrank WH, Joynt Maddox KE. Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries: Implications for Social Risk Adjustment and Health Equity. JAMA HEALTH FORUM 2023; 4:e230266. [PMID: 37000433 PMCID: PMC10066453 DOI: 10.1001/jamahealthforum.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
Importance Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. Objective To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Design, Setting, and Participants Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Exposures Census block group-level ADI. Main Outcomes and Measures Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Results Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.
Collapse
Affiliation(s)
- Brian W. Powers
- Tufts University School of Medicine, Boston, Massachusetts
- MassGeneral Brigham, Boston, Massachusetts
- Humana Inc, Louisville, Kentucky
| | - Jose F. Figueroa
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Suhas Gondi
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | |
Collapse
|
6
|
How Does the Effect of the Comprehensive Care for Joint Replacement Model Vary Based on Surgical Volume and Costs of Care? Med Care 2023; 61:20-26. [PMID: 36223537 DOI: 10.1097/mlr.0000000000001785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Center for Medicare and Medicaid Innovation revised the comprehensive Care for Joint Replacement (CJR) program, a mandatory 90-day bundled payment for lower extremity joint replacement, in December 2017, retaining 34 of the original 67 metropolitan statistical areas with higher volume and historic episode payments. OBJECTIVES We describe differences in costs, quality, and patient selection between hospitals that continued to participate compared with those that withdrew from CJR before and after the implementation of CJR. RESEARCH DESIGN We used a triple difference approach to compare the magnitude of the policy effect for elective admissions between hospitals that were retained in the CJR revision or not, before and after the implementation of CJR, and compared with hospitals in nonparticipant metropolitan statistical areas. SUBJECTS 694,275 Medicare beneficiaries undergoing elective lower extremity joint replacement from January 1, 2013 to August 31, 2017. MEASURES The treatment effect heterogeneity of CJR. RESULTS Hospitals retained in the CJR policy revision had a greater reduction in 90-day episode-of-care cost compared with those that were allowed to discontinue (-$846, 95% CI: -$1,338, -$435) and had greater cost reductions in the more recent year (2017). We also found evidence that retained CJR hospitals disproportionately reduced treating patients who were older than 85 years. CONCLUSIONS Hospitals that continued to participate in CJR after the policy revision achieved a greater cost reduction. However, the cost reductions were partly attributed to avoiding potential higher - cost patients, suggesting that a bundled payment policy might induce disparities in care delivery.
Collapse
|
7
|
Offodile AC, Gibbons JB, Murrell S, Kinzer D, Sharfstein JM, Sharfstein J. A Global Equity Model (GEM) for the Advancement of Community Health and Health Equity. NAM Perspect 2022; 2022:202211b. [PMID: 36713771 PMCID: PMC9875856 DOI: 10.31478/202211b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
8
|
Lin E, Bozic KJ, Ibrahim S, O'Connor MI, Nelson CL. Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations?: AOA Critical Issues. J Bone Joint Surg Am 2022; 104:e92. [PMID: 35841318 DOI: 10.2106/jbjs.21.01332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients.
Collapse
Affiliation(s)
- Eugenia Lin
- Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Kevin J Bozic
- Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Said Ibrahim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Mary I O'Connor
- Vori Health, Jacksonville Beach, Florida.,Movement is Life, Washington, D.C
| | - Charles L Nelson
- Movement is Life, Washington, D.C.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
Hung A, Hall R. How a Medicare payment model is affecting care for older adults with Alzheimer's disease and related dementias. J Am Geriatr Soc 2022; 70:2478-2480. [PMID: 35792555 PMCID: PMC9489652 DOI: 10.1111/jgs.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022]
Abstract
This Editorial comments on the article by Kim et al. in this issue.
Collapse
Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Rasheeda Hall
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, NC
| |
Collapse
|
10
|
Gondi S, Joynt Maddox K, Wadhera RK. "REACHing" for Equity - Moving from Regressive toward Progressive Value-Based Payment. N Engl J Med 2022; 387:97-99. [PMID: 35801977 DOI: 10.1056/nejmp2204749] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Suhas Gondi
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
| | - Karen Joynt Maddox
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
| | - Rishi K Wadhera
- From the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.), and Brigham and Women's Hospital (S.G.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, School of Medicine, and the Center for Health Economics and Policy, Washington University in St. Louis, St. Louis (K.J.M.)
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Abstract
The United States healthcare system underperforms in healthcare access, quality, and cost resulting in some of the poorest health outcomes among comparable countries, despite spending more of its gross national product on healthcare than any other country in the world. Within the United States, there are significant healthcare disparities based on race, ethnicity, socioeconomic status, education level, sexual orientation, gender identity, and geographic location. COVID-19 has illuminated the racial disparities in health outcomes. This article provides an overview of some of the main concepts related to health disparities generally, and in orthopaedics specifically. It provides an introduction to health equity terminology, issues of bias and equity, and potential interventions to achieve equity and social justice by addressing commonly asked questions and then introduces the reader to persistent orthopaedic health disparities specific to total hip and total knee arthroplasty.
Collapse
Affiliation(s)
- Susan Salmond
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| | - Caroline Dorsen
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| |
Collapse
|
13
|
Thirukumaran CP, Ricciardi BF, Cai X, Holloway RG, Li Y, Glance LG. Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias. JAMA HEALTH FORUM 2022; 3:e215111. [PMID: 35977279 PMCID: PMC8903111 DOI: 10.1001/jamahealthforum.2021.5111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Question Is the Comprehensive Care for Joint Replacement (CJR) model associated with changes in hip and knee replacement use for Medicare beneficiaries with Alzheimer disease and related dementias (ADRD)? Findings In this cohort study of 24 598 729 beneficiary-year observations among 9 624 461 unique beneficiaries, CJR was statistically significantly associated with a decrease in hip replacement use for beneficiaries with and without ADRD; however, the gap in use between these groups did not change with CJR implementation. The CJR model was not associated with changes in knee replacement use. Meaning This study found that the CJR model was not associated with a disproportionate reduction in joint replacement use for Medicare beneficiaries with ADRD. Importance Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare’s mandatory bundled payment reform—the Comprehensive Care for Joint Replacement (CJR) model—was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design, Setting, and Participants This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, −0.13 to −0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, −0.12 to −0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, −0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: −0.03, 95% CI, −0.09 to 0.02; P = .27). Conclusions and Relevance In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.
Collapse
Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, New York
- Department of Public Health Sciences, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, New York
| | - Robert G. Holloway
- Department of Neurology, University of Rochester, New York
- Department of Medicine, University of Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| |
Collapse
|
14
|
Ko H, Martin BI, Nelson RE, Pelt CE. Patient selection in the Comprehensive Care for Joint Replacement model. Health Serv Res 2022; 57:72-90. [PMID: 34612519 PMCID: PMC8763283 DOI: 10.1111/1475-6773.13880] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/17/2021] [Accepted: 09/10/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To understand whether the Comprehensive Care for Joint Replacement (CJR) program induces participating hospitals to (1) preferentially select lower risk patients, (2) reduce 90-day episode-of-care costs, (3) improve quality of care, and (4) achieve greater cost reduction during its second year, when downside financial risk was applied. DATA SOURCES We identified beneficiaries of age 65 years or older undergoing hip or knee joint replacement in the 100% sample of Medicare fee-for-service inpatient (Part A) claims from January 1, 2013 to August 31, 2017. Cases were linked to subsequent outpatient, Part B, home health agency, and skilled nursing facility claims, as well as publicly available participation status for CJR. STUDY DESIGN We estimated the effect of CJR for hospitals in the 67 metropolitan statistical areas (MSA) selected to participate in CJR (785 hospitals), compared to those in 104 non-CJR MSAs (962 hospitals; maintaining fee-for-service). A difference-in-differences approach was used to detect patient selection, as well as to compare 90-day episode-of-care costs and quality of care between CJR and non-CJR hospitals over the first two performance years. DATA COLLECTION We excluded 172 hospitals from our analysis due to their preexisting BPCI participation. We focused on elective admissions in the main analysis. PRINCIPAL FINDINGS While reductions in 90-day episode-of-care costs were greater among CJR hospitals (-$902, 95% CI: -$1305, -$499), largely driven by a 16.8% (p < 0.01) decline in 90-day spending in skilled nursing facilities, CJR hospitals significantly reduced the 90-day readmission rate (-3.9%; p < 0.05) and preferentially avoided patients aged 85 years or older (-5.9%; p < 0.01) and Black (-7.0%; p < 0.01). Cost reduction was greater in 2017 than in 2016, corresponding to the start of downside risk. CONCLUSIONS Participation in CJR was associated with a modest cost reduction and a reduction in 90-day readmission rates; however, we also observed evidence of preferential avoidance of older patients perceived as being higher risk among CJR hospitals.
Collapse
Affiliation(s)
- Hyunkyu Ko
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
| | - Brook I. Martin
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
| | - Richard E. Nelson
- Division of EpidemiologyUniversity of UtahSalt Lake CityUtahUSA,Utah Department of Veterans AffairsSalt Lake CityUtahUSA
| | - Christopher E. Pelt
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
| |
Collapse
|
15
|
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] [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.
Collapse
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
Collapse
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
| |
Collapse
|