To prevent cherry picking of patients who need total joint arthroplasty, a presenter urged CMS to adjust bundled payments upward for several patient demographic factors.
“Based on our results, total joint arthroplasty TJA bundled payments should be adjusted upward for age, [American Society for Anesthesiologists] ASA class, hip fractures, non-white race and medical comorbidities and complications,” Scott M. Eskildsen, MD, an orthopedic surgery resident at the UNC School of Medicine, said. “Given the way bundled payments are given by preoperative payment, future bundled adjustments should not use postop factors, such as major complications/comorbid conditions] MCCs and should only use preop factors such as demographics,” he said.
Upward adjustment needed
For this study, Eskildsen and his colleagues collected financial data for Medicare patients who underwent 1,493 unilateral TJAs during a 2-year period. To represent appropriate adjustment levels, they used an in-hospital accounting system to identify variable hospital costs. Postoperative care costs were predicted based on previous literature, Eskildsen noted. Researchers used multivariate regression to identify the clinical and demographic factors they used for risk stratification.
Results showed an increased TJA cost among patients over 65 years of age.
“Every year over the age of 65 showed an increased cost of $121” for these procedures, Eskildsen said. “Therefore, a patient over 70 years old had an approximately $600 increased cost compared to a patient who was 65.”
Eskildsen reported there was a $1,769 increase in cost of the surgery for every increase in ASA class and the procedure cost was $6,223 greater for patients who underwent hip fracture surgery. Patients with MS-DRG 469, which is an MCC modifier for acute medical complications, had an increased cost of $5,665 for their procedures and non-white patients had a higher cost vs. white patients.
“We also, importantly, did not find any association between cost and BMI or gender,” Eskildsen said.
Importance of risk adjustment
Eskildsen told Healio.com/Orthopedics CMS should increase reimbursement for the MS-DRG 469 modifier, but he noted CMS should eventually phase out the policy because it essentially rewards complications.
“A better approach would be to risk-adjust for all comorbidities independently, which would reward providers who care for challenging patients, not those who experience complications,” he said.
Risk adjustment is “particularly imperative with bundled payments” so all patients receive treatment regardless of risk status, according to Eskildsen.
“Risk adjustment has always been important, but it is particularly imperative with bundled payments,” Eskildsen told Healio.com/Orthopedics. “Under traditional fee-for-service, surgeons were relatively insulated from adverse incentives because they received similar payment regardless of the case, while hospitals saw more variation in reimbursement. With bundled payments, surgeons share payments with the hospital, so financial incentives may be more likely to impact their patient selection and potentially create barriers to care for certain patients,” he said. – by Casey Tingle
Clement RC, et al. Paper #332. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting. March 14-18, 2017; San Diego.
Scott M. Eskildsen, MD, can be reached at UNC Health Care, 101 Manning Dr., Chapel Hill, NC 27514; email: firstname.lastname@example.org.
Disclosure: Eskildsen reports no relevant financial disclosures.