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CJR program may reduce institutional spending for hip, knee replacement
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Results published in the New England Journal of Medicine showed a modest reduction in spending per hip or knee replacement episode without an increase in rates of complications within the first 2 years of the Comprehensive Care for Joint Replacement program.
“Bundled payments are a promising new model to help align financial incentives between hospitals, post-acute care and outpatient care. In joint replacement, they save money without negative effects, but prior studies have relied on comparing volunteer hospitals to control hospitals,” Michael L. Barnett, MD, MS, lead author of the study and assistant professor of health policy and management at Harvard T. H. Chan School of Public Health, told Healio.com/Orthopedics. “We evaluated the first-ever nationally randomized experience in bundled payments, which provides strong evidence for savings in joint replacement, though they were modest.”
Using Medicare claims from 2015 through 2017, Barnett and his colleagues conducted difference-in-difference analyses that encompassed the first 2 years of bundled payments in the Comprehensive Care for Joint Replacement (CJR) program. Before and after implementation of the CJR program, researchers evaluated hip or knee replacement episodes and compared the 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program with 121 control areas. Researchers also adjusted the analyses for the hospital, as well as patient and procedure characteristics. Primary outcomes included institutional spending per hip or knee replacement episode, rates of postsurgical complications and the percentage of “high-risk” patients.
Overall, researchers identified 280,161 hip or knee replacement procedures performed in 803 hospitals participating in the CJR program and 377,278 procedures in 962 hospitals in control areas. Results showed areas participating in the CJR program had greater decreases in institutional spending per joint replacement episode vs. control areas after the initiation of the CJR model. Researchers noted a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities largely contributed to the differential reduction. However, researchers found no significant differential effect on the composite rate of complications or the percentage of joint replacement procedures performed in high-risk patients with implementation of the CJR program.
“Even when forced into a new payment model, on average, hospitals can save money in joint replacements episodes largely by reducing the use of nursing and rehabilitation facilities in favor of home health care,” Barnett said. “There was no evidence of negative effects, but we need further research on patient-centered outcomes to be sure.” – by Casey Tingle
Disclosures: Barnett reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
Back to TopB. Sonny Bal, MD, MBA, JD, PhD
The 2-year data from mandatory bundled payments for arthroplasty confirm that there are underlying institutional costs that can be trimmed, without affecting outcomes or access to care. In other words, opportunities for institutional cost-savings and efficiencies are being compelled by external pressures, such as reduced reimbursement, bundled payments and other mechanisms. Institutional leadership should proactively explore redundancies and cost efficiencies, especially in light of evidence-based medicine, and particularly in a commoditized, high-volume procedure such as arthroplasty. The prevailing health care environment will undoubtedly continue to address costs aggressively.
Perspective
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R. Michael Meneghini, MD
Barnett and colleagues reported modest savings within the mandatory CJR program largely through a reduction in post-acute rehab services. It is not surprising that complications were unaffected, as research consistently shows the post-acute care facilities are associated with poorer outcomes. Further, strong financial incentives encouraged this shift by hospitals. The real question remains: What is next in bundled payment reform? Hospitals and surgeons will now look to their own practices to squeeze out additional savings, which has potential challenges. They will need to monitor outcomes closely as the “race to the bottom” for maximum savings within bundled payment models continues, which all indications suggest it will.
Perspective
Back to TopAndrew M. Pepper, MD
The article titled “Two-year evaluation of mandatory bundled payments for joint replacement” is a timely and thoroughly performed analysis of the effect the CJR mandatory bundled payment model has on cost and quality of care for hip and knee arthroplasty. I commend the authors for highlighting the lack of risk stratification in the CJR model, and it is reassuring that no care discrimination was observed during the first 2-year period of implementation. Further careful evaluation of care access trends in this payment model will be necessary in order to ensure care equality to patients.
Andrews Institute for Orthopaedics & Sports Medicine
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