In the JournalsPerspective

Joint replacement program may reduce margin for savings vs bundled payment model

James D. Slover

Published results showed use of the Comprehensive Care for Joint Replacement model may substantially reduce the margin for savings compared with the Bundled Payments for Care Improvement model.

Using historical data from NYU Langone Orthopedic Hospital, James D. Slover, MD, MS, and colleagues calculated the mean cost per episode of care of major joint replacement or reattachment of a lower extremity with or without major complications or comorbidities and with or without fracture. Researchers established and comparatively analyzed the target prices, projected savings or losses per episode of care and projected annual savings for both Bundled Payments for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) models.

Results showed a decrease in CJR target price by 24% for major joint replacement or reattachment of a lower extremity with major complications or comorbidities for patients without fracture and 22.8% for patients with fracture compared with BPCI target prices. For major joint replacement or reattachment of a lower extremity without major complications or comorbidities, researchers found a decrease in CJR target prices of 26.1% and 27.7% for patients without vs. with fracture, respectively. Researchers noted CJR may result in a reduction in savings per episode of care by 92.8% and by 166% for major joint replacement or reattachment of a lower extremity with major complications or comorbidities for patients without and with fracture, respectively. There may also be a reduction in savings per episode of care by 94.9% for major joint replacement or reattachment of a lower extremity without major complications or comorbidities in patients without fractures and by 61.7% in patients with fractures, according to results. Under CJR, researchers found a decrease in their institution’s projected annual savings of 83.3%.

“CJR is an alternative bundled payment program that encourages and rewards quality and efficiency of care,” Slover told Healio.com/Orthopedics. “Success will require continued ongoing improvement and innovation efforts, even for centers that have had success in previous bundled payment programs, such as BPCI.” – by Casey Tingle

 

Disclosures: Slover reports he is a steering committee member for the AJRR Hip Society; a board member of the American Association of Hip and Knee Surgeons, Hip Society, Knee Society and PCORI Advisory Board for Shared Decision-Making; receives payment for lectures including service on speakers bureaus from Pacira; and research support from Biomet and Smith & Nephew. Please see the study for a list of all other authors’ relevant financial disclosures.

James D. Slover

Published results showed use of the Comprehensive Care for Joint Replacement model may substantially reduce the margin for savings compared with the Bundled Payments for Care Improvement model.

Using historical data from NYU Langone Orthopedic Hospital, James D. Slover, MD, MS, and colleagues calculated the mean cost per episode of care of major joint replacement or reattachment of a lower extremity with or without major complications or comorbidities and with or without fracture. Researchers established and comparatively analyzed the target prices, projected savings or losses per episode of care and projected annual savings for both Bundled Payments for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) models.

Results showed a decrease in CJR target price by 24% for major joint replacement or reattachment of a lower extremity with major complications or comorbidities for patients without fracture and 22.8% for patients with fracture compared with BPCI target prices. For major joint replacement or reattachment of a lower extremity without major complications or comorbidities, researchers found a decrease in CJR target prices of 26.1% and 27.7% for patients without vs. with fracture, respectively. Researchers noted CJR may result in a reduction in savings per episode of care by 92.8% and by 166% for major joint replacement or reattachment of a lower extremity with major complications or comorbidities for patients without and with fracture, respectively. There may also be a reduction in savings per episode of care by 94.9% for major joint replacement or reattachment of a lower extremity without major complications or comorbidities in patients without fractures and by 61.7% in patients with fractures, according to results. Under CJR, researchers found a decrease in their institution’s projected annual savings of 83.3%.

“CJR is an alternative bundled payment program that encourages and rewards quality and efficiency of care,” Slover told Healio.com/Orthopedics. “Success will require continued ongoing improvement and innovation efforts, even for centers that have had success in previous bundled payment programs, such as BPCI.” – by Casey Tingle

 

Disclosures: Slover reports he is a steering committee member for the AJRR Hip Society; a board member of the American Association of Hip and Knee Surgeons, Hip Society, Knee Society and PCORI Advisory Board for Shared Decision-Making; receives payment for lectures including service on speakers bureaus from Pacira; and research support from Biomet and Smith & Nephew. Please see the study for a list of all other authors’ relevant financial disclosures.

    Perspective
    Michael P. Bolognesi

    Michael P. Bolognesi

    This is an important study that highlights some of the challenges around episode of care payment and the entire transition to value-based care. It is unfortunate the changes in reimbursement around CJR appear to be creating a losing situation for those groups that are participating or will participate based on the author’s study. We know that efforts made by knee and hip arthroplasty surgeons to participate in and support CJR and BCPI programs has led to notable savings for CMS and we are hopeful these programs can remain a viable way for us to keep working to decrease health care expenditures. This study makes it clear that we will have to continually look at payments around episode of care programs going forward.

    • Michael P. Bolognesi, MD
    • Professor
      Chief of the division of adult reconstruction
      Department of orthopedic surgery
      Duke University Medical Center
      AAHKS President
      Durham, North Carolina

    Disclosures: Bolognesi reports no relevant financial disclosures.

    Perspective
    James I. Huddleston III

    James I. Huddleston III

    The study “Comparison of payment margins between the bundled payments for care initiative and the comprehensive care for joint replacement model shows a marked reduction for a successful program” by Jorge A. Padilla, MD, and colleagues highlights two concerns previously voiced by the American Association of Hip and Knee Surgeons, namely the mandatory nature of the CJR program, as well as the CJR precedence over the Bundled Payment for Care Initiative program. The rapidly decreasing reference prices for an episode of care, as determined by regional pricing structures, has been characterized by many as a “race to the bottom.” The high bar set to obtain quality points provides further disincentive for participation. Ultimately, aggressive downward pressure on reference pricing will limit access to arguably two of the most effective medical interventions.

    AAHKS maintains its cornerstone position that the transition to value-based care should be led by physicians. We are leading the way among all specialties in this journey and we, as well as our patients and hospital partners, should not be penalized for our success in increasing the value of hip and knee arthroplasty.

    • James I. Huddleston III, MD
    • Associate professor of orthopedic surgery department of orthopedic surgery
      Stanford University Medical Center
      AAHKS Advocacy Committee Chair
      Redwood City, California

    Disclosures: Huddleston reports no relevant financial disclosures.