Advertisement

The Effect of CMS's Comprehensive Care for Joint Replacement Bundled Payment Model on Trajectories of Post-acute Rehabilitation Care After Total Hip Arthroplasty

      Abstract

      Objective

      To evaluate the effect of the Comprehensive Care for Joint Replacement (CJR) policy on the 90-day trajectory of post-acute care after a total hip arthroplasty (THA).

      Design

      Multivariable difference-in-difference models applied to Medicare beneficiaries undergoing a THA prior to (2014-2015) and post-CJR implementation (2017) in areas subjected to or exempt from the policy.

      Setting

      Hospitals in standard metropolitan statistical areas.

      Participants

      357,844 elderly Medicare patients nationwide undergoing THA (N=357,844).

      Interventions

      None.

      Main Outcome Measures

      Escalation in care to institutionalization (ie, admission to an inpatient rehabilitation or skilled nursing facility during 90-days postdischarge for those initially discharged to the community and return to the community at the end of the episode of care among those initially discharged to an institutional setting).

      Results

      Of the 357,844 elderly Medicare patients nationwide undergoing THA during the study period, 47.6% were discharged directly to the community and 52.4% received post-acute care in an institution. Patients discharged to an institution post-policy in a CJR area were about 10% less likely to return to the community (odds ratio=0.91; 95% confidence interval, 0.84-0.98; P=.02) at the end of the 90-day episode of care than those treated in policy-exempt areas. Despite the large magnitude, estimates of escalation in care among patients treated in bundling areas post-CJR implementation were not statistically significant.

      Conclusions

      Our findings support further exploration of unanticipated effects of mandatory bundled payment policies on outcomes, as well as further examination of outcomes among policy-relevant subgroups of patients undergoing hip replacement in the United States.

      Keywords

      List of abbreviations:

      BPCI (Bundled Payments for Care Improvement Initiative), CI (confidence interval), CJR (Comprehensive Care for Joint Replacement), CMS (Centers for Medicare & Medicaid Services), DRG (diagnosis-related group), ICD (International Classification of Diseases), IRF (inpatient rehabilitation facility), OR (odds ratio), SMSA (standard metropolitan statistical area), SNF (skilled nursing facility), THA (total hip arthroplasty)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Katz JN
        • Arant KR
        • Loeser RF.
        Diagnosis and treatment of hip and knee osteoarthritis: a review.
        JAMA. 2021; 325: 568-578
      1. Agency for Healthcare Research and Quality. HCUP fast stats—most common operations during inpatient stays. Available at: https://www.hcup-us.ahrq.gov/faststats/NationalProceduresServlet. Accessed May 20, 2021.

        • Singh JA
        • Yu S
        • Chen L
        • Cleveland JD.
        Rates of total joint replacement in the United States: future projections to 2020-2040 using the National Inpatient Sample.
        J Rheumatol. 2019; 46: 1134-1140
      2. Centers for Medicare and Medicaid Services. Comprehensive care for joint replacement model. Available at: https://innovation.cms.gov/innovation-models/cjr. Accessed May 31, 2021.

      3. Centers for Medicare & Medicaid Services (CMS). Medicare program: Comprehensive Care for Joint Replacement Model. Three-year extension and changes to episode definition and pricing. Available at: https://www.federalregister.gov/public-inspection/current. Accessed October 15, 2021

        • Haas DA
        • Zhang X
        • Kaplan RS
        • Song Z.
        Evaluation of economic and clinical outcomes under Centers for Medicare & Medicaid Services mandatory bundled payments for joint replacements.
        JAMA Intern Med. 2019; 179: 924-931
        • Barnett ML
        • Wilcock A
        • McWilliams JM
        • et al.
        Two-year evaluation of mandatory bundled payments for joint replacement.
        N Engl J Med. 2019; 380: 252-262
        • Finkelstein A
        • Ji Y
        • Mahoney N
        • Skinner J.
        Mandatory Medicare bundled payment program for lower extremity joint replacement and discharge to institutional postacute care.
        JAMA. 2018; 320: 892-900
        • Agarwal R
        • Liao JM
        • Gupta A
        • Navathe AS.
        The impact of bundled payment on health care spending, utilization, and quality: a systematic review.
        Health Aff. 2020; 39: 50-57
        • Sabeh KG
        • Rosas S
        • Buller LT
        • Roche MW
        • Hernandez VH.
        The impact of discharge disposition on episode-of-care reimbursement after primary total hip arthroplasty.
        J Arthroplast. 2017; 32: 2969-2973
        • Wilcock AD
        • Barnett ML
        • McWilliams JM
        • Grabowski DC
        • Mehrotra A.
        Hospital responses to incentives in episode-based payment for joint surgery.
        JAMA Intern Med. 2021 May 17; ([Epub ahead of print])
        • Li Y
        • Ying M
        • Cai X
        • Thirukumaran CP.
        Association of mandatory bundled payments for joint replacement with postacute care outcomes among Medicare and Medicaid dual eligible patients.
        Med Care. 2021; 59: 101-110
        • Quan H
        • Sundararajan V
        • Halfon P
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Elixhauser A
        • Steiner C
        • Harris DR
        • Coffey RM.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Athey S
        • Imbens GW.
        Identification and inference in nonlinear difference-in-differences models.
        Econometrica. 2006; 74: 431-497
        • Schroer WC
        • Diesfeld PJ
        • LeMarr AR
        • Morton DJ
        • Reedy ME.
        Hip fracture does not belong in the elective arthroplasty bundle: presentation, outcomes, and service utilization differ in fracture arthroplasty care.
        J Arthroplast. 2018; 33: S56-S60
        • Cairns MA
        • Moskal PT
        • Eskildsen SM
        • Ostrum RF
        • Clement RC.
        Are Medicare's “Comprehensive Care for Joint Replacement” bundled payments stratifying risk adequately?.
        J Arthroplast. 2018; 33: 2722-2727
      4. Centers for Medicare & Medicaid Services. CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1717-FC). Available at: https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center. Accessed May 1, 2021.

      5. The Lewin Group, Inc. CMS Comprehensive Care for Joint Replacement Model: performance year 4 evaluation report. Available at: https://innovation.cms.gov/data-and-reports/2021/cjr-py4-annual-report. Accessed January 6, 2022.