Two new JAMA reports show how CMS bundled payment models for lower extremity joint replacement (LEJR) surgery had positive affects on patient care and, in some cases, cut costs.
One study found that the Comprehensive Care for Joint Replacement (CJR) program for the procedure led to a significantly lower percentage of discharges to institutional post-acute care. However, the study authors found no significant difference in total Medicare spending per episode.
CMS views bundled payments as a way to reduce costs, improve quality and give providers more control over their patients' care. CMS has moved nearly one-third of fee-for-service payments to alternative payment models, and bundled payments are a popular choice.
Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries. CMS said there were more than 400,000 procedures in 2014, which cost more than $7 billion in hospitalizations alone. These procedures also result in long recovery and rehabilitation periods. Quality and costs of care for these procedures vary widely, according to the agency.
"The rate of complications like infections or implant failures after surgery can be more than three times higher at some facilities than others, increasing the chances that the patient may be readmitted to the hospital. And the average Medicare expenditure for surgery, hospitalization and recovery ranges from $16,500 to $33,000 across geographic areas," CMS has said.
In an editorial about the studies in JAMA, Andrew Ryan, who is with UnitedHealthcare and the University of Michigan, said the findings are encouraging.
"Given the increasing number of joint replacements at younger and younger ages, it is important that these procedures be a focus of cost and quality initiatives. The findings ... suggest that prospective payment to hospitals can be improved through common sense and straightforward bundled payment reforms. These programs should be continued and expanded, particularly for patients undergoing elective surgical procedures," Ryan wrote.
He questioned, however, whether bundled payment successes for joint replacement can relate to other procedures. Much of the savings in bundled payment programs occur in post-acute care and clinical facilities. Procedures and chronic disease episodes that don't include that care may not find those kinds of savings, he wrote.
The new study on CJR looked at discharges to institutional post-acute care after LEJR episodes for Medicare patients in 2016. The authors analyzed the first year of a five-year randomized trial of 75 metropolitan statistical areas assigned the bundled payment model and 121 control MSAs.
They found that the mean percentage of LEJR admissions discharged to institutional post-acute care was 33.7% in the control group and 2.9 percentage points lower in the CJR group.
Mean Medicare spending for institutional post-acute care per LEJR episode was $3,871 in the control group. The CJR group was $307 less. Mean overall Medicare spending per episode was $22,872 in the control group. The CJR group was $453 less, which the researchers called statistically nonsignificant.
They also found the two groups didn't differ in other metrics, such as number of days in institutional post-acute care, discharges to other locations, Medicare spending during the episode, net Medicare spending during the episode, LEJR patient volume and patient case mix and quality-of-care measures.
The second study looked at 1.7 million Medicare beneficiaries who underwent LEJR in a hospital participating in the BPCI initiative.
It found that being part of BPCI didn't affect patient volume for the procedure. One concern is that hospitals may move toward healthier patients for BPCI since the model doesn't take into account the patient's condition. However, the study found that wasn't a problem in the research, which "may provide reassurance" about unintended consequences, the authors wrote.