Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias

Abstract

IMPORTANCE Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. OBJECTIVETo evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. DESIGN, SETTING, AND PARTICIPANTS This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. EXPOSURES Implementation of the CJR model in 2016. MAIN OUTCOMES AND MEASURESOutcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. RESULTSThe study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, −0.13 to −0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, −0.12 to −0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, −0.08 to 0.09; (continued) Key Points Question Is the Comprehensive Care for Joint Replacement (CJR) model associated with changes in hip and knee replacement use for Medicare beneficiaries with Alzheimer disease and related dementias (ADRD)? Findings In this cohort study of 24 598 729 beneficiary-year observations among 9 624 461 unique beneficiaries, CJ...

Association of Medicare bundled payment model with joint replacement care for people with dementia

“…Consistent with our finding, one study found that CJR did not lead hospitals to decrease admission of high‐risk patients for joint replacement, although the definition of high‐risk patients in the previous studies was broad 14 . Focusing on Medicare enrollees with an arthritis diagnosis, another study also found that CJR did not lead hospitals to selectively avoid elective joint replacement for people with ADRD 30 …”

“…14 Focusing on Medicare enrollees with an arthritis diagnosis, another study also found that CJR did not lead hospitals to selectively avoid elective joint replacement for people with ADRD. 30 Our finding-no changes in the receipt of joint replacement under CJR among people with ADRD-may be potential because hospitals instead successfully reduced spending for these medically complex patients. The CJR model was associated with a $1029 reduction in total spending for people with ADRD (3.1% reduction from total spending in the pre-CJR period).…”

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“…This study's findings are reassuring, but also highlight areas of improvement. First, the CJR Model has not led to reduced joint replacement surgeries in ADRD patients, a finding consistent with another recent study 8 . Second, this study demonstrates that the CJR Model has decreased spending among ADRD patients while maintaining quality of care, at least when evaluating 90‐day hospital readmissions, 90‐day emergency department use, 90‐day mortality, and functional status improvement as measured by ADL score.…”

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“…The bundled payment system compensates providers for managing a patient's medical condition across the entire care continuum, encompassing all services, procedures, tests, medications, and devices involved in the treatment of specific conditions, such as lower extremity joint replacement. Lower extremity joint replacement bundle payment programs have demonstrated reduced episodic spending and resulted in maintained or improved quality of care in patients 105,106 …”