P. Maxwell Courtney

Are Bundled Payments a Viable Reimbursement Model for Revision Total Joint Arthroplasty

BackgroundAlternative payment models, such as the Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative, aim to decrease overall costs for hip and knee arthroplasties.Questions/purposesWe asked: (1) Is there any difference in the CMS episode-of-care costs, hospital length of stay, and readmission rate from before and after implementation of our bundled-payment program? (2) Is there any difference in reimbursements and resource utilization between revision THA and TKA at our institution? (3) Are there any independent risk factors for patients with high costs who may not be appropriate for a bundled-payment system for revision total joint arthroplasty (TJA)?MethodsBetween October 2013 and March 2015, 218 patients underwent revision TKA or THA in one health system. Two hundred seventeen patients were reviewed as part of this study, and one patient with hemophilia was excluded from the analysis as an outlier. Our institution began a BPCI program for revision TJA during this study period. Patients’ procedures done before January 1, 2014 at one hospital and January 1, 2015 at another hospital were not included in the bundled-care arrangement (70 revision TKAs and 56 revision THAs), whereas 50 revision TKAs and 41 revision THAs were performed under the BPCI initiative. Patient demographics, medical comorbidities, episode-of-care reimbursement data derived directly from CMS, length of stay, and readmission proportions were compared between the bundled and nonbundled groups.ResultsLength of stay in the group that underwent surgery before the bundled-care arrangement was longer than for patients whose procedures were done under the BPCI (mean 4.02 [SD, 3.0 days] versus mean 5.27 days [SD, 3.6 days]; p = 0.001). Index hospitalization reimbursement for the bundled group was less than for the nonbundled group (mean USD 17,754 [SD, USD 2741] versus mean USD 18,316 [SD, USD 4732]; p = 0.030). There was no difference, with the numbers available, in total episode-of-care CMS costs between the two groups (mean USD 38,107 [SD, USD 18,328] versus mean USD 37,851 [SD, USD 17,208]; p = 0.984). There was no difference, with the numbers available, in the total episode-of-care CMS costs between revision hip arthroplasties and revision knee arthroplasties (mean USD 38,627 [SD, USD 18,607] versus mean USD 37,414 [SD, USD 16,884]; p = 0.904). Disposition to rehabilitation (odds ratio [OR], 5.49; 95% CI, 1.97–15.15; p = 0.001), length of stay 4 days or greater (OR, 3.66; 95% CI, 1.60–8.38; p = 0.002), and readmission within 90 days (OR, 6.99; 95% CI, 2.58–18.91; p < 0.001) were independent risk factors for high-cost episodes.ConclusionsBundled payments have the potential to be a viable reimbursement model for revision TJA. Owing to the unpredictable nature of the surgical procedures, inherent high risks of complications, and varying degrees of surgical complexity, future studies are needed to determine whether bundling patients having revision TJA will result in improved care and decreased costs.Level of EvidenceLevel IV, economic and decision analysis.

Is bilateral total knee arthroplasty staged at a one-week interval safe? A matched case control study.

Controversy surrounds the safety of bilateral total knee arthroplasty (TKA) and whether staging the procedures one week apart represents a safer option. A consecutive series of 234 patients underwent either a simultaneous (103 patients) or staged bilateral TKA (131 patients) from 2007 to 2012 and were compared to a matched control group of unilateral TKA (131 patients). Staged patients had no difference in one-year complication rate when compared to simultaneous bilateral TKA and the matched unilateral TKA control group (15% vs. 19% vs. 15%, P=0.512). There was also no difference in perioperative complications (10% vs. 14% vs. 7%, P=0.231) or 90-day readmissions (8% vs. 4% vs. 4%, P=0.295). In selected patients with bilateral knee OA, TKA staged at a one-week interval is a safe alternative.

Can Bundled Payments Be Successful in the Medicaid Population for Primary Joint Arthroplasty

BACKGROUND Although some bundled payment models have had success in total joint arthroplasty, concerns exist about access to care for higher cost patients who use more resources. The purpose of this study is to determine whether Medicaid patients have increased hospital costs and more resource utilization in a 90-day episode of care than Medicare or privately insured patients. METHODS We retrospectively reviewed a consecutive series of 7268 primary hip and knee arthroplasty patients at a single institution. Using a propensity score-matching algorithm for demographic variables, we matched the 92 consecutive Medicaid patients with 184 privately insured and 184 Medicare patients. Hospital-specific costs, discharge disposition, complications, and 90-day readmissions were analyzed. RESULTS Medicaid patients had higher mean inpatient hospital costs than both of the matched Medicare and privately insured groups (

Risk Adjustment Is Necessary in Medicare Bundled Payment Models for Total Hip and Knee Arthroplasty

15,396 vs

Reconsidering the Affordable Care Act’s Restrictions on Physician-owned Hospitals: Analysis of Cms Data on Total Hip and Knee Arthroplasty

12,165 vs

Should Medicare Remove Total Knee Arthroplasty From Its Inpatient Only List? A Total Knee Arthroplasty Is Not a Partial Knee Arthroplasty

13,864, P < .001) with longer length of stay (3.34 vs 2.49 vs 1.46 days, P < .001). Medicaid and Medicare patients were more likely to be discharged to a rehabilitation facility than privately insured patients (17% vs 21% vs 1%, P < .001). When controlling for demographic factors and comorbidities, Medicaid insurance was a significant independent risk factor for increased hospital costs (odds ratio 3.64, 95% confidence interval 1.80-7.38, P < .001). CONCLUSION Because of increased hospital costs, current bundled payment models should not include Medicaid patients because of concerns about patient selection and access to care. Further study is needed to determine whether bundling Medicaid arthroplasty costs in a stand-alone program with a separate target price will result in improved outcomes and decreased costs.

A Systematic Approach to Evaluating Hip Radiographs-A Focus on Osteoarthritis

BACKGROUND Concerns exist that high-risk patients in alternative payment models may face difficulties with access to care without proper risk adjustment. The purpose of this study is to identify the effect of medical and orthopedic specific risk factors on the cost of a 90-day episode of care following total hip (THA) and knee arthroplasty (TKA). METHODS We queried the Medicare 5% Limited Data Set for all patients undergoing primary THA and TKA from 2010 to 2014. To evaluate the cost of an episode of care, we calculated all claims for 90 days following surgery. Multivariate analysis was performed to quantify the added episode-of-care costs for demographic variables, geography, medical comorbidities, and orthopedic specific risk factors. RESULTS Of the 58,809 TKA patients, the median 90-day Medicare costs was

In Brief: Closed Tibial Shaft Fractures

23,800 (interquartile range,

Maximizing Physician-Hospital Alignment: Lessons Learned From Effective Models of Joint Arthroplasty Care

18,900-

Synovial Fluid Alpha-Defensin Is an Adjunctive Tool in the Equivocal Diagnosis of Periprosthetic Joint Infection

32,300), while the median of the 27,293 THA patients was