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Haglin JM, Brinkman JC, Austin RP, Deckey DG, Christopher ZK, Spangehl MJ, Bingham JS. Risk Versus Reward: Hospitals Incentivized More Than Surgeons to Care for Riskier Arthroplasty Patients. J Arthroplasty 2024; 39:S71-S75. [PMID: 38735550 DOI: 10.1016/j.arth.2024.05.006] [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: 01/11/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). METHODS The "2021 Medicare Physician and Other Provider" and "2021 Medicare Inpatient Hospitals" files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker cohort" with an HCC risk score of 1.5 or more and a "healthier cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts. RESULTS In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001). CONCLUSIONS This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.
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Affiliation(s)
- Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Roman P Austin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
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Kebeh M, Dlott CC, Kurek D, Morris JC, Johnson CB, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series. Orthop Nurs 2024; 43:2-9. [PMID: 38266257 PMCID: PMC10832337 DOI: 10.1097/nor.0000000000000997] [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] [Indexed: 01/26/2024] Open
Abstract
Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.
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Affiliation(s)
- Martha Kebeh
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Chloe C Dlott
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Donna Kurek
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jensa C Morris
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Charla B Johnson
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Daniel H Wiznia
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Pennestrì F, Lega F, Banfi G. From volume to value: Improving peri-operative elective pathways through a roadmap from fast-track orthopedic surgery. Health Serv Manage Res 2023; 36:284-290. [PMID: 36444939 PMCID: PMC10552341 DOI: 10.1177/09514848221127623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Healthcare institutions face the pressure generated by modern medicine and society, in terms of increasing expectations and financial constraints. Chronic patients need multidisciplinary care pathways to preserve their wellbeing across the entire journey.The orthopaedic community has been particularly receptive in testing solutions to align good clinical outcomes and financial sustainability, given the increase in elective procedures provided among aging populations to alleviate pain and reduce disability. Fast-track (FT) total joint arthroplasty (TJA) and bundled payments (BPs) offer relevant examples both from the clinical and the financial perspective; however, they have not been evaluated in combination yet.The aim of this manuscript is to provide a road map to improve the value of high-volume, multidisciplinary elective procedures, with potential applications in a vast number of surgical specialties, (1) based on an integrated financial budget per episode of care (the BP), (2) building on lessons from a review of the literature on FT TJA.Although clinical outcomes vary from procedure to procedure, the coordination between the single treatments and providers involved across the patient journey; the commitment of patients and relatives; and the systematic adoption of patient-reported outcomes; can add further value for the benefit of patients, healthcare funders and providers, once essential clinical, financial and administrative conditions are guaranteed.
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Affiliation(s)
| | - Federico Lega
- Research Center on Health Administration, University of Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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4
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Kebeh M, Dlott CC, Tung WS, Kurek D, Johnson CB, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care. Orthop Nurs 2023; 42:279-288. [PMID: 37708523 PMCID: PMC10662942 DOI: 10.1097/nor.0000000000000968] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.
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Affiliation(s)
- Martha Kebeh
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Wei Shao Tung
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Donna Kurek
- National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL, USA
- OrthoVirginia, Chesterfield, VA, USA
| | - Charla B. Johnson
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Haglin JM, Brinkman JC, Moore ML, Deckey DG, Christopher ZK, Tummala SV, Spangehl MJ, Bingham JS. The Current Relationship Between Surgeon Reimbursement and Patient Complexity in Arthroplasty-A Risk-Payment Analysis of All Primary Joint Replacements Billed to Medicare in 2019. J Arthroplasty 2023; 38:S50-S53. [PMID: 36828053 DOI: 10.1016/j.arth.2023.02.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The purpose of this study was to assess surgeon reimbursement among total joint arthroplasty (TJA) patients who had differing risk profiles within the Medicare population. METHODS The "2019 Medicare Physician and Other Provider" file was utilized. In 2019, 441,584 primary total hip and knee arthroplasty procedures were billed to Medicare Part B. All episodes were included. Patient demographics and comorbidity profiles were collected for all patients. Additionally, mean patient hierarchal condition category (HCC) risk scores and physician reimbursements were collected. All procedure episodes were split into 2 cohorts; those with an HCC risk score of 1.5 or greater, and those with patient HCC risk scores less than 1.5. Variables were averaged for each cohort and compared. RESULTS The mean reimbursement across all procedures was $1,068.03. For the sicker patient cohort with a mean HCC risk score of 1.5 or greater, there was a significantly higher rate of all comorbidities compared to the cohort with HCC risk score under 1.5. The mean payment across the sicker cohort was $1,059.21, while the mean payment among the cohort with HCC risk score under 1.5 was 1,073.32 (P = .032). CONCLUSION This study demonstrates that for Medicare patients undergoing primary TJA in 2019, the mean surgeon reimbursement was lower for primary TJA among sick patients in comparison to their healthier counterparts, although it is difficult to ascertain the impact of this discrepancy. As alternative payment models continue to undergo evaluation and development, these data will be important for the potential advancement of more equitable reimbursement models in arthroplasty care, specifically regarding surgeon reimbursement and possible risk adjustment within such models.
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Affiliation(s)
- Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Michael L Moore
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
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6
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Bernstein JA, Rana A, Iorio R, Huddleston JI, Courtney PM. The Value-Based Total Joint Arthroplasty Paradox: Improved Outcomes, Decreasing Cost, and Decreased Surgeon Reimbursement, Are Access and Quality at Risk? J Arthroplasty 2022; 37:1216-1222. [PMID: 35158003 DOI: 10.1016/j.arth.2022.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Adam Rana
- Department of Orthopedics and Sports Medicine, Maine Medical Center, Portland, ME
| | - Richard Iorio
- Brigham and Women's Hospital, Harvard Medical School, Department of Orthopaedic Surgery, Boston, MA
| | | | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty. J Am Acad Orthop Surg 2022; 30:e799-e807. [PMID: 35594512 DOI: 10.5435/jaaos-d-21-00247] [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] [Received: 05/11/2021] [Accepted: 02/14/2022] [Indexed: 02/01/2023] Open
Abstract
Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.
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8
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Zanotto BS, Etges APBDS, Marcolino MAZ, Polanczyk CA. Value-Based Healthcare Initiatives in Practice: A Systematic Review. J Healthc Manag 2021; 66:340-365. [PMID: 34192716 PMCID: PMC8423138 DOI: 10.1097/jhm-d-20-00283] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
EXECUTIVE SUMMARY Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.
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Affiliation(s)
- Bruna Stella Zanotto
- National Institute of Health Technology Assessment and Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Paula Beck da Silva Etges
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul, and Pontifical Catholic University of Rio Grande do Sul Polytechnic School, Porto Alegre, Brazil
| | - Miriam Allein Zago Marcolino
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul and Graduate Program in Epidemiology, Federal University of Rio Grande do Sul; and
| | - Carisi Anne Polanczyk
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul, and Graduate Programs in Epidemiology and Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul
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Keswani AH, Snyder DJ, Ahn A, Austin DC, Jayakumar P, Grauer JN, Poeran J, Bozic KJ, Moschetti WE, Jevsevar DS, Galatz LM, Bronson MJ, Chen DD, Moucha CS. Metric Selection, Metric Targets, and Risk Adjustment Should be Considered in the Design of Gainsharing Models for Bundled Payment Programs in Total Joint Arthroplasty. J Arthroplasty 2021; 36:801-809. [PMID: 33199096 DOI: 10.1016/j.arth.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Under bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons' performance in gainsharing models. METHODS Patients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons' performance designation: scenario 1 used "aspirational targets" (>60th percentile), scenario 2 used "acceptable targets" (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool. RESULTS In total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance. CONCLUSION Quality metric/target selection and risk adjustment profoundly impact surgeons' performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the "cherry picking" of patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aakash H Keswani
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | | | - Amy Ahn
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel C Austin
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX; Harkness Fellowship in Health Care Policy and Practice Innovation, Commonwealth Fund. New York, NY
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Wayne E Moschetti
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Michael J Bronson
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Darwin D Chen
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
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Lieberz D, Regal R, Conway P. Observational Study: Predictors of a Successful Functional Outcome in Persons Who Receive Physical Therapy for Knee Osteoarthritis. Eval Health Prof 2020; 45:137-146. [PMID: 32878456 DOI: 10.1177/0163278720954229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A retrospective design was employed to determine what factors are predictive of achieving a successful outcome for individuals with knee osteoarthritis following an episode of physical therapy. Success was defined as achieving the minimum clinically important difference with the change in the lower extremity functional scale (LEFS). Receiving guideline adherent care was hypothesized to increase odds of success. Data for treatment interventions, health care utilization, patient characteristics, and LEFS scores were collected from electronic health records from 2014-2018 across 34 outpatient clinics. The sample (N = 706) was primarily female, White, and older adults. Receiving guideline adherent care did not predict odds of achieving success. Patient age, initial LEFS score, opioid prescription, number of visits, and Medicare/Medicaid insurance were predictive of the outcome. Increasing age after 65 years predicted decreased odds of success. Older adults showed improved odds with an opioid prescription and with increased number of visits from two through 18 therapy sessions. Opportunities exist for further health services research on optimal management of knee OA, including underutilization of physical therapy (only 6% in this study), measuring adherence to CPGs, determining recommended intensity for interventions, and the effects of non-physical therapy interventions such as opioid use on outcomes.
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Affiliation(s)
| | - Ronald Regal
- 218993Essentia Institute of Rural Health, Duluth, MN, USA
| | - Pat Conway
- 218993Essentia Institute of Rural Health, Duluth, MN, USA
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11
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Krueger CA, Austin MS, Levicoff EA, Saxena A, Nazarian DG, Courtney PM. Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty. J Arthroplasty 2020; 35:2318-2322. [PMID: 32423758 DOI: 10.1016/j.arth.2020.04.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature. METHODS We prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff. RESULTS Although the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes. CONCLUSION Surgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.
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Affiliation(s)
- Chad A Krueger
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Eric A Levicoff
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Arjun Saxena
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - David G Nazarian
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - P Maxwell Courtney
- Department of Orthopaedics, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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12
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Co-Morbidities and Sex Differences in Long-Term Quality-of-Life Outcomes among Patients with and without Diabetes after Total Knee Replacement: Five-Year Data from Registry Study. J Clin Med 2019; 9:jcm9010019. [PMID: 31861688 PMCID: PMC7019834 DOI: 10.3390/jcm9010019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022] Open
Abstract
Improved understanding of quality-of-life (QoL) outcomes can provide valuable information on intervention effectiveness and guide better patient care. The aim of this study was to examine whether QoL trajectories differ between patients with and without diabetes and identify to what extent patient characteristics are related to poor QoL outcomes after total joint replacement (TKR). Multilevel modelling was used to analyse long-term QoL patterns of patients undergoing TKR between 2006 and 2011. Patient-reported QoL at baseline and up to 5 years post-surgery were included. Of the 1553 TKR patients, one-fifth (n = 319) had diabetes. Despite there being no significant differences in QoL at baseline, patients with diabetes consistently reported lower QoL (on average by 0.028, p < 0.001) and did not improve to the same level as patients without the disease following surgery. Compared to males, females had significantly lower QoL (by 0.03, p < 0.001). Other baseline patient characteristics associated with important differences in QoL included presence of respiratory disease and mental health disorder. Patients with diabetes exhibit significantly poorer QoL compared to patients without diabetes, particularly among females. Knowledge of risk factors that impact on QoL can be useful for clinicians in identifying characteristics related to poor QoL outcomes and be used to guide patient-centered care.
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Value-based Healthcare: Improving Outcomes through Patient Activation and Risk Factor Modification. Clin Orthop Relat Res 2019; 477:2418-2420. [PMID: 31567580 PMCID: PMC6903833 DOI: 10.1097/corr.0000000000000985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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