Performance Of Safety-Net Hospitals In Year 1 Of The Comprehensive Care For Joint Replacement Model

Abstract

The Comprehensive Care for Joint Replacement (CJR) model of 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study, we used Medicare’s CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals’ rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend might place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients might enable safety-net hospitals to compete effectively in CJR.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement

“… 9 , 10 , 46 , 47 This rationale for unfavorable selection is further supported by concerns that the investments made in quality improvement in preparation for payment reforms and the resulting capabilities may motivate hospitals to increase their case volumes with perceived healthier patients, thereby leaving out beneficiaries from racial/ethnic minority groups and increasing the existing disparities. 5 Furthermore, the absence of having to consider sociodemographic risk adjustment places an increased burden on safety net hospitals, 48 , 49 , 50 and these hospitals may be particularly cautious in selecting socially vulnerable patients for surgical procedures. Potential explanations for CJR model–associated disparities in TKRs and not in THRs are likely to be a greater need for institutional rehabilitation after TKRs, especially for beneficiaries from racial/ethnic minority groups, 51 , 52 higher adverse events, 53 and longer recovery.…”

Socioeconomic Status and the Experience of Pain: An Example from Knees

“…However, other data suggest this is not likely to be materially important. Complication rates for hip and knee replacements are similar across hospitals with different rates of low income patients, with the exception that the quintile of hospitals with the fewest low income patients has lower complication rates than the remaining 80% (Thirukumaran et al, 2019). Overall, therefore, this evidence does not suggest that differential access to medical care explains the difference in knee pain by education.…”

The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes

“…[4][5][6][7][8] In the context of bundled payments for joint replacement surgery, safety net hospitals have been less likely to achieve financial savings but more likely to receive penalties. [9][10][11] Moreover, the savings achieved by safety net hospitals have been smaller than those achieved by non-safety net hospitals. 12 Despite these concerning findings, there are few data about how safety net hospitals have fared under bundled payments for common medical conditions.…”