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



      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).


      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.


      Hospitals in standard metropolitan statistical areas.


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



      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).


      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.


      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.


      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)
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