A Preliminary Examination of the CMS Eligibility Criteria in Total-Joint Arthroplasty

Predictors of Discharge Settings After Total Knee Arthroplasty in Medicare Patients

OBJECTIVES

To determine the factors associated with acute hospital discharge to the 3 most common postacute settings following total knee arthroplasty (TKA): inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and directly back to the community.

DESIGN

Retrospective cohort study.

SETTING

Acute care hospitals submitting claims to Medicare.

PARTICIPANTS

National cohort (N=1,189,286) of 100% Medicare Part A data files from 2009-2011.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Observed rates and adjusted odds of discharge to the 3 main postacute settings based on the clinical and facility level variables: amount of comorbidity, bilateral procedures, and facility TKA volume.

RESULTS

Using IRF discharge as the reference, patients who received a bilateral procedure had lower odds of both SNF and community discharge, patients with more comorbidity had lower odds for community discharge and higher odds for SNF discharge, and patients who received their TKA from hospitals with lower TKA volumes had lower odds of SNF and community discharge.

CONCLUSIONS

Clinical populations within Medicare beneficiaries may systematically vary across the 3 most common discharge settings following TKA. This information may be helpful for a better understanding on which patient or clinical factors influence postacute care settings following TKA. Additional research including functional status, living situation, and social support systems would be beneficial.

What Financial Incentives Will Be Created by Medicare Bundled Payments for Total Hip Arthroplasty?

BACKGROUND

Bundled payments are gaining popularity in arthroplasty as a tactic for encouraging providers and hospitals to work together to reduce costs. However, this payment model could potentially motivate providers to avoid unprofitable patients, limiting their access to care. Rigorous risk adjustment can prevent this adverse effect, but most current bundling models use limited, if any, risk-adjustment techniques. This study aims to identify and quantify the financial incentives that are likely to develop with total hip arthroplasty (THA) bundled payments that are not accompanied by comprehensive risk stratification.

METHODS

Financial data were collected for all Medicare-eligible patients (age 65+) undergoing primary unilateral THA at an academic center over a 2-year period (n = 553). Bundles were considered to include operative hospitalizations and unplanned readmissions. Multivariate regression was performed to assess the impact of clinical and demographic factors on the variable cost of THA episodes, including unplanned readmissions. (Variable costs reflect the financial incentives that will emerge under bundled payments).

RESULTS

Increased costs were associated with advanced age (P < .001), elevated body mass index (BMI; P = .005), surgery performed for hip fracture (P < .001), higher American Society of Anaesthesiologists (ASA) Physical Classification System grades (P < .001), and MCCs (Medicare modifier for major complications; P < .001). Regression coefficients were $155/y, $107/BMI point, $2775 for fracture cases, $2137/ASA grade, and $4892 for major complications. No association was found between costs and gender or race.

CONCLUSION

If generalizable, our results suggest that Centers for Medicare and Medicaid Services bundled payments encompassing acute inpatient care should be adjusted upward by the aforementioned amounts (regression coefficients above) for advanced age, increasing BMI, cases performed for fractures, elevated ASA grade, and major complications (as defined by Medicare MCC modifiers). Furthermore, these figures likely underestimate costs in many bundling models which incorporate larger proportions of postdischarge care. Failure to adjust for factors affecting costs may create barriers to care for specific patient populations.

Risk Adjustment for Medicare Total Knee Arthroplasty Bundled Payments

The use of bundled payments is growing because of their potential to align providers and hospitals on the goal of cost reduction. However, such gain sharing could incentivize providers to "cherry-pick" more profitable patients. Risk adjustment can prevent this unintended consequence, yet most bundling programs include minimal adjustment techniques. This study was conducted to determine how bundled payments for total knee arthroplasty (TKA) should be adjusted for risk. The authors collected financial data for all Medicare patients (age≥65 years) undergoing primary unilateral TKA at an academic center over a period of 2 years (n=941). Multivariate regression was performed to assess the effect of patient factors on the costs of acute inpatient care, including unplanned 30-day readmissions. This analysis mirrors a bundling model used in the Medicare Bundled Payments for Care Improvement initiative. Increased age, American Society of Anesthesiologists (ASA) class, and the presence of a Medicare Major Complications/Comorbid Conditions (MCC) modifier (typically representing major complications) were associated with increased costs (regression coefficients, $57 per year; $729 per ASA class beyond I; and $3122 for patients meeting MCC criteria; P=.003, P=.001, and P<.001, respectively). Differences in costs were not associated with body mass index, sex, or race. If the results are generalizable, Medicare bundled payments for TKA encompassing acute inpatient care should be adjusted upward by the stated amounts for older patients, those with elevated ASA class, and patients meeting MCC criteria. This is likely an underestimate for many bundling models, including the Comprehensive Care for Joint Replacement program, incorporating varying degrees of postacute care. Failure to adjust for factors that affect costs may create adverse incentives, creating barriers to care for certain patient populations. [Orthopedics. 2016; 39(5):e911-e916.].

What Incentives Are Created by Medicare Payments for Total Hip Arthroplasty?

BACKGROUND

Differences in profitability and contribution margin (CM) between various patient populations may make certain patients particularly attractive (or unattractive) to providers. This study seeks to identify patient characteristics associated with increased profit and CM among Medicare patients undergoing total hip arthroplasty (THA).

METHODS

The expected Medicare reimbursement for consecutive patients of Medicare-eligible age (65+ years) undergoing primary unilateral elective THA (n = 498) was calculated in accordance with Center for Medicare and Medicaid Services policy. Costs were derived from the hospital's cost accounting system. Profit and CM were calculated for each patient as reimbursement less total and variable costs, respectively. Patients were compared based on clinical and demographic factors by univariate and multivariate analyses.

RESULTS

Medicare patients undergoing THA generated negative average profits but substantial positive CMs. Lower profit and CM were associated with higher American Society of Anesthesiologists Physical Status Classification (P < .01, P = .03), older age (P < .01), and longer length of stay (P < .01, P = .03). No association was found with gender, body mass index, or race.

CONCLUSION

If our results are generalizable, Medicare patients requiring THA are currently financially attractive, but institutions have a long-term incentive to shift resources to more profitable patients and service lines, which may eventually restrict access to care for this population. THA providers have a financial incentive to favor Medicare patients with younger age, lower American Society of Anesthesiologists Physical Status Classification, and those who can be expected to require relatively short admissions. The Center for Medicare and Medicaid Services must strive to accurately match reimbursement rates to provider costs to avoid inequitable payments to providers and financial incentives discouraging treatment of high-risk patients or other patient subpopulations.

The use of adaptive equipment following total knee replacement

Introduction

This study evaluates the need for adaptive equipment following total knee replacement. There are no recent studies to guide occupational therapists in the optimum time adaptive equipment is required following total knee replacement.

Method

A non-experimental, concurrent mixed methods approach was used. The study population was patients attending for total knee replacement at a large general hospital. Outcome measures were the Oxford Knee Score, the United Kingdom Functional Independence Measure and a weekly diary.

Results

A total of 19 patients were included in the study. Following assessment, 53% ( n = 10) required adaptive equipment following total knee replacement. No significant difference was found in pre-operative pain or function scores, gender or surgical pathway when comparing those who did and did not need adaptive equipment post-operatively. Patients who required adaptive equipment post-operatively had significantly worse pain ( p = 0.030) and function ( p = 0.040) at 6 weeks post-operatively and had significantly longer inpatient stay ( p = 0.041).

Conclusion

Although there are resource implications, patients requiring adaptive equipment following total knee replacement should be assessed by occupational therapy staff 6 weeks post-operatively to ensure optimal functional outcomes following surgery.

Assessing disability in morbidly obese individuals: the Italian Society of Obesity test for obesity-related disabilities

PURPOSE

To validate a new obesity-specific disability assessment test: the Obesity-related Disability test (Test SIO Disabilità Obesità Correlata, TSD-OC).

METHODS

Adult obese individuals were assessed with the TSD-OC, 36-Item Short-Form Health Survey (SF-36), 6-min walking test (6MWT) and grip strength. The TSD-OC is composed of 36 items divided into seven sections (pain, stiffness, activities of daily living and indoor mobility, housework, outdoor activities, occupational activities and social life). Statistical correlations between the TSD-OC, functional assessment (6MWT and grip strength) and quality of life parameters (SF-36) were analysed. Internal consistency was assessed with Cronbach's α test. Test-retest reliability was evaluated in a subgroup of 30 individuals. A linking exercise between TSD-OC items and categories of the International Classification of Functioning, Disability and Health was performed.

RESULTS

Test-retest showed excellent stability (r = 0.90) and excellent internal consistency was reported (Cronbach's α > 0.90). Significant low to moderate correlations between TSD-OC, SF-36 scores, 6MWT and grip strength were observed. A total of 26 ICF categories were linked, mostly related to the area of mobility.

CONCLUSIONS

The TSD-OC is a reliable and valid instrument for measuring self-reported disability in obese subjects. It may represent an important tool for establishing rehabilitation needs in individuals with obesity-related disability, for planning appropriate rehabilitation programmes and for evaluating their effectiveness.

A multicenter examination of the Center for Medicare Services eligibility criteria in total-joint arthroplasty

OBJECTIVE

The Centers for Medicare and Medicaid Services (CMS) use a diagnostic category (revised in 2004) as one of eight criteria to determine whether a hospital is eligible for payment as an inpatient rehabilitation facility (IRF). Among the 13 specific categories of patients, there are three particular ones involving total knee arthroplasty (TKA) and hip arthroplasty (THA) patients. The purpose of this investigation was to analyze inpatient rehabilitation outcomes in TKA and THA patients, using these CMS criteria.

DESIGN

A multicenter, retrospective study using a consecutive patient sample from 15 independent inpatient rehabilitation facilities, conducted from January 1, 2002 through March 31, 2006. All patients had either primary or revision TKA or THA and were directly admitted for inpatient rehabilitation postacute care. Patients were 23,274 men and women, separated into three comparison pairs on the basis of CMS eligibility criteria: (1) unilateral or bilateral arthroplasty, (2) age <85 yrs or >or=85 yrs, or (3) body mass index (BMI) <50 or >or=50 kg/m2. All patients underwent a comprehensive rehabilitation program that included physical and occupational therapies for 3 hrs/day. Main outcomes were inpatient rehabilitation length of stay (LOS), functionality as assessed by the FIM instrument, FIM efficiency, hospital charges, and discharge disposition.

RESULTS

FIM efficiency scores were 8-21% lower in bilateral arthroplasties and patients aged >or=85 yrs, respectively (P < 0.0001). LOS was an average of 33% longer in patients >or=85 yrs than among patients <85 yrs (3.4 days; P < 0.0001). Total charges were 12-30% higher for patients with BMI >or=50 kg/m and >85 yrs than their comparative groups (P < 0.001). Arthroplasty patients <85 yrs were discharged more often to home compared with those >or=85 yrs (P = 0.0001). Patients >or=85 yrs were more likely to be transferred to a skilled nursing facility (7.4%) or back to acute care (3.9%) than those <85 yrs.

CONCLUSIONS

All arthroplasty patients demonstrated improved physical function after inpatient rehabilitation. Those aged >or=85 yrs demonstrated the lowest efficiency, the greatest cost, and were the least likely to return home.

Association between body mass index and functional independence measure in patients with deconditioning

OBJECTIVE

To assess the association of body mass index (BMI) with functional independence measure (FIM) score in patients with deconditioning. We also examined whether the association was different for motor and cognitive subscales of the FIM instrument.

DESIGN

A retrospective study of 1077 inpatients admitted to the general medicine service for deconditioning at an acute rehabilitation hospital. Patients were classified into underweight (BMI < 18.5), normal range (BMI = 18.5-24.9), overweight (BMI = 25.0-29.9), obese class I (BMI = 30.0-34.9), obese class II (BMI = 35.0-39.9), and obese class III (BMI > or = 40).

RESULTS

Median gain in FIM scores from admission to discharge was highest in obese class I patients (27 points), followed by obese class II patients (26 points). The most gain in FIM scores was accounted for by the motor subscale. Adjusting for age, gender, and length of in-hospital stay, obese class I patients had a 5.8-point (95% confidence limits = 1.2, 7.0) higher gain in FIM score compared with patients with BMI in the normal range.

CONCLUSIONS

In an acute rehabilitation setting, obese patients had higher gains in FIM scores as compared with normal-range-BMI patients. Most of the improvements in FIM scores were accounted for by the motor subscale, with little or no improvement on the cognitive scale.