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Chen DQ, Parvataneni HK, Miley EN, Deen JT, Pulido LF, Prieto HA, Gray CF. Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly. J Arthroplasty 2023; 38:S54-S62. [PMID: 36781061 PMCID: PMC10839807 DOI: 10.1016/j.arth.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. METHODS Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. RESULTS Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. CONCLUSION The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.
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Affiliation(s)
- Dennis Q Chen
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Hari K Parvataneni
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Emilie N Miley
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Justin T Deen
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Luis F Pulido
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Hernan A Prieto
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Chancellor F Gray
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
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Haglin JM, Arthur JR, Deckey DG, Makovicka JL, Pollock JR, Spangehl MJ. Temporal Analysis of Medicare Physician Reimbursement and Procedural Volume for all Hip and Knee Arthroplasty Procedures Billed to Medicare Part B From 2000 to 2019. J Arthroplasty 2021; 36:S121-S127. [PMID: 33637380 DOI: 10.1016/j.arth.2021.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/24/2021] [Accepted: 02/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000. METHODS The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type. RESULTS From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019. CONCLUSION This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward.
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Affiliation(s)
- Jack M Haglin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | | | - Jordan R Pollock
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
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Schwarzkopf R, Behery OA, Yu H, Suter LG, Li L, Horwitz LI. Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty. J Arthroplasty 2019; 34:2304-2307. [PMID: 31279598 PMCID: PMC7011860 DOI: 10.1016/j.arth.2019.05.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications. METHODS We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories. RESULTS Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all). CONCLUSION Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.
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Affiliation(s)
- Ran Schwarzkopf
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Omar A Behery
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - HuiHui Yu
- Section of Rheumatology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Lisa G Suter
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, CT; Section of Rheumatology, Department of Medicine, Yale School of Medicine, New Haven, CT; West Haven Veterans Administration Medical Center, West Haven, CT
| | - Li Li
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, CT
| | - Leora I Horwitz
- Division of Healthcare Delivery Science, Center for Healthcare Innovation and Delivery Science, Department of Population Health, NYU School of Medicine, NYU Langone Health, New York, NY; Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, NYU Langone Health, New York, NY
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Sood N, Shier V, Nakata H, Iorio R, Lieberman JR. The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery. J Arthroplasty 2019; 34:609-612.e1. [PMID: 30612831 PMCID: PMC6430686 DOI: 10.1016/j.arth.2018.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.
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Affiliation(s)
- Neeraj Sood
- Corresponding author, Neeraj Sood, PhD, Sol Price School of Public Policy and Schaeffer Center for Health Policy and Economics, University of Southern California, Verna & Peter Dauterive Hall Suite 512, 635 Downey Way, Los Angeles, California, 90089; 213-821-7949;
| | - Victoria Shier
- Schaeffer Center for Health Policy, University of Southern California; Verna & Peter Dauterive Hall Suite 512, 635 Downey Way, Los Angeles, California, 90089;
| | - Haley Nakata
- Keck School of Medicine of University of Southern California; 1975 Zonal Ave, Los Angeles, CA 90033;
| | - Richard Iorio
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery; 75 Francis Street Boston, MA 02115;
| | - Jay R. Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California; 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033;
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Schroer WC, Diesfeld PJ, LeMarr AR, Morton DJ, Reedy ME. Modifiable Risk Factors in Primary Joint Arthroplasty Increase 90-Day Cost of Care. J Arthroplasty 2018; 33:2740-2744. [PMID: 29807789 DOI: 10.1016/j.arth.2018.04.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/29/2018] [Accepted: 04/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Risk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care. METHODS An electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m2), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared. RESULTS Mean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor. CONCLUSIONS Medical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.
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Affiliation(s)
- William C Schroer
- SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis Joint Replacement Institute, St. Louis, Missouri
| | - Paul J Diesfeld
- SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis Joint Replacement Institute, St. Louis, Missouri
| | - Angela R LeMarr
- SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis Joint Replacement Institute, St. Louis, Missouri
| | - Diane J Morton
- SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis Joint Replacement Institute, St. Louis, Missouri
| | - Mary E Reedy
- SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis Joint Replacement Institute, St. Louis, Missouri
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Rosner BI, Gottlieb M, Anderson WN. Effectiveness of an Automated Digital Remote Guidance and Telemonitoring Platform on Costs, Readmissions, and Complications After Hip and Knee Arthroplasties. J Arthroplasty 2018; 33:988-996.e4. [PMID: 29229238 DOI: 10.1016/j.arth.2017.11.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/02/2017] [Accepted: 11/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The impact of a new class of automated digital patient engagement (DPE) platforms on potentially avoidable costs, hospital admissions, and complications after discharge following hip and knee arthroplasties has not been established. METHODS We conducted a multicenter observational cohort study comparing claims data for potentially avoidable costs, hospital admissions, and complications for 90 days after discharge following hip and knee arthroplasties at 10 practice sites in CA and NV. One hundred eighty-six patients, enrolled between 2014 and 2016 on an automated DPE platform receiving guidance and remote monitoring perioperatively, were compared with 372 patients who underwent the same procedures from the same physicians within 3 years immediately preceding platform implementation. The primary end point was the proportion of patients with $0.00 in 90-day target costs because of potentially avoidable utilization within the platform's influence. Secondary end points included rates of potentially avoidable 90-day hospital admissions and composite complications. RESULTS Ninety-three percent and 84.7% of the study and baseline cohorts, respectively, had $0.00 in target costs (P = .004), with a mean savings of $656.52/patient (P = .006). The baseline and study cohorts had 3.0% and 1.6% 90-day hospital admission rates (relative risk 0.545; 0.154, 1.931, P = .40), and 15.3% and 7.0% composite complication rates, respectively (relative risk 0.456; 0.256, 0.812, P = .004). CONCLUSION Patients enrolled on an automated DPE platform after hip and knee arthroplasties demonstrated a significant reduction in potentially avoidable 90-day costs, a 45.4% nonsignificant relative reduction in 90-day hospital admissions, and a 54.4% significant relative reduction in 90-day complications.
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Kim K, Iorio R. The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm. J Arthroplasty 2017; 32:1712-1716. [PMID: 28292629 DOI: 10.1016/j.arth.2017.02.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms. METHODS We summarize a number of experiences and lessons learned since the implementation of Bundled Payments for Care Improvement at our institution. RESULTS Our experience has led to the development of more refined clinical pathways and coordination of care through evidence-based approaches. We have established that the success of the bundled payment program rests on the following 5 main clinical pillars: (1) optimizing patient selection and comorbidities; (2) optimizing care coordination, patient education, shared decision making, and patient expectations; (3) using a multimodal pain management protocol and minimizing narcotic use to facilitate rapid rehabilitation; (4) optimizing blood management, and standardizing venous thromboembolic disease prophylaxis treatment by risk standardizing patients and minimizing the use of aggressive anticoagulation; and (5) minimizing post-acute facility and resource utilization, and maximizing home resources for patient recovery. CONCLUSION From our extensive experience with bundled payment models, we have established 5 clinical pillars of value for bundled payments. Our hope is that these principles will help ease the transition to value-based care for less-experienced healthcare systems.
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Affiliation(s)
- Kelvin Kim
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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