Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center

Abstract

BackgroundTotal joint arthroplasty (TJA) remains the highest expenditure in the Centers for Medicare and Medicaid Services (CMS) budget. One model to control cost is the Comprehensive Care for Joint Replacement (CJR) model. There has been no published literature to date examining the efficacy of CJR on value-based outcomes. The purpose of this study was to determine the efficacy and sustainability of a multidisciplinary care redesign for total joint arthroplasty under the CJR paradigm at an academic tertiary care center.MethodsWe implemented a system-wide care redesign, affecting all patients who underwent a total hip or total knee arthroplasty at our academic medical center. The main study outcomes were cost (to CMS), discharge destination, complications and readmissions, and length of stay (LOS); these were measured using the 2017 initial CJR reconciliation report, as well as our institutional database.ResultsThe study included 1536 patients (41% Medicare). Per-episode cost to CMS declined by 19.5% to 11% below the CMS-designated national target. Home discharge increased from 62% to 87%. CMS readmissions declined from 15% to 6%; major complications decreased from 2.3% to 1.9%; and LOS declined from 3.6 to 2.1 days.ConclusionsA mandatory episode-based bundled-payment program can induce favorable changes to value-based metrics, improving quality and outcomes for health-care consumers. Quality and value were improved in this study, evidenced by lower 90-day episode cost, more home discharges, lower readmissions and complications, and shorter LOS. This approach has implications not just for CMS, but for private payers, corporate health programs, and fixed-budget health-care models.

Variation of the Inpatient Cost of Care in the Treatment of Isolated Geriatric Intertrochanteric Hip Fractures

“… 17 Another study by Gray et al over a 1 year period also showed improved quality and value of care with implementation of CJR bundled model compared with the previous year. 18 Surgical Hip and Femur Fracture Treatment (SHFFT) is a 90-day bundle modeled after CJR that nearly became mandatory in 2018. It is only a matter of time before alternative payment models for hip fracture care become mandatory.…”

Transition to outpatient total hip and knee arthroplasty: experience at an academic tertiary care center

“…The redesign was focused on improved pain control, enhanced recovery, reduction in complications and readmissions, and reduced costs. Since its inception, there has been a consistent decrease in the hospital length of stay, reduced complications and readmissions, an increase in the rate of discharge to home, and a decrease in the rate of discharge to skilled nursing facilities [13] .…”

“…As part of an institutional, patient-centered quality initiative, we implemented a major redesign of total joint arthroplasty (TJA) care starting in November 2015 [13] . The goal of this initiative was to maintain high standards for patient safety and outcome quality while simultaneously reducing costs.…”

Outpatient total knee arthroplasty: is it economically feasible in the hospital setting?

“…The differences in perioperative efficiency and incentivization likely explains our data, which shows that our HOPD was overall significantly more cost-effective than our AMC on a cost-perminute basis. These results come in a context where national health care expenditures in the United States are projected to increase to nearly 20% of the gross domestic product by the year 2020 [18], and in which regulatory measures to control spending on TJA episodes are being rapidly implemented by the Centers for Medicare and Medicaid Services (CMS) [19]. In fact, the regulatory landscape for patients undergoing TKA is quickly changing: in 2018, TKA was removed from the CMS inpatient-only list and is expected to be approved for payment in the ASC setting as of January 2020.…”