High Bundled Payment Costs Following Total Hip and Knee Arthroplasty in African Americans

BackgroundConcerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients.MethodsWe queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs.ResultsCompared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001).ConclusionAfrican American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.     

Staging Total Hip and Knee Arthroplasty Procedures Within 90 Days Increases Costs in Bundled Payment Programs

BackgroundUnder current Medicare bundled payment programs, when a patient undergoes a subsequent elective procedure within the 90-day episode-of-care, the first procedure is excluded from the bundle and a new episode-of-care initiated. The purpose of this study was to determine if staging bilateral total hip (THA) and total knee arthroplasty (TKA) procedures within 90 days have an effect on bundled episode-of-care costs.MethodsWe reviewed a consecutive series of Medicare patients undergoing staged primary THA and TKA from 2015-2019. Patients who underwent a prior procedure within 90 days were compared to those who had undergone a procedure 90-120 days prior. We then performed a multivariate analysis to identify the independent effect of staging timeframe on costs and outcomes.ResultsOf the 136 patients undergoing a staged bilateral THA or TKA, 48 patients underwent staged procedures within 90 days (35%) and 88 patients between 91-120 days (65%). There were no significant differences observed for demographics, comorbidities, complications, readmissions, or discharge disposition (all P > .05). Patients undergoing a staged procedure within 90 days had increased episode-of-care costs by $2021 (95% CI $11-$4032, P = .049), increased postacute care costs by $2019 (95% CI $66-$3971, P < .001), and reduced per-patient margin by $2868 (95% CI-$866-$4869, P = .005).DiscussionPatients undergoing staged bilateral THA or TKA within 90 days have increased episode-of-care costs compared to those undergoing a staged procedure from 91-120 days. Since patients may still not be fully recovered from the first procedure, CMS should address the inappropriate allocation of costs to ensure institutions are not penalized.     

The Effects of Bundled Payment Programs for Hip and Knee Arthroplasty on Patient-Reported Outcomes

BackgroundPatient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes after hip and knee arthroplasty based on hospital participation in Medicare’s bundled payment programs.MethodsWe performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively.ResultsRelative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (−1.8 point relative difference at 6 months; 95% confidence interval −3.2 to −0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (−2.3 point relative difference at 6 months; 95% confidence interval −4.0 to −0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference.ConclusionsPatients receiving care at hospitals participating in Medicare’s bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.     

The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm

Background

Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms.

Inpatient Consults and Complications During Primary Total Joint Arthroplasty in a Bundled Care Model

Background

The Centers for Medicare and Medicaid Services (CMS) are implementing changes in hospital reimbursement models for total joint arthroplasty (TJA), moving to value-based bundled payments from the fee-for-service model. The purpose of this study is to identify consults and complications during the perioperative period that increase financial burden.

The Cost of an Episode of Care in a Total Knee Arthroplasty Patient Is More Than a Total Hip Arthroplasty Patient Within an Alternative Payment Model

BackgroundAlternative payment models were set up to increase the value of care for total joint arthroplasty. Currently, total knee arthroplasty (TKA) and total hip arthroplasty (THA) are reimbursed within the same bundle. We sought to determine whether it was appropriate for these cases to be included within the same bundle.MethodsThe data were collected from consecutive patients in a bundled payment program at a single large academic institution. All payments for 90 days postoperatively were included in the episode of care. Readmission rates, demographics, and length of stay were collected for each episode of care.ResultsThere was a significant difference in cost of episode of care between TKA and THA, with the average TKA episode-of-care cost being higher than the average THA episode-of-care cost ($25803 vs $23805, P < .0001). There was a statistically significant difference between the 2 groups between gender, race, medical complexity, disposition outcome, and length of stay. The TKA group trended toward a lower readmission rate (5.3%) compared to the THA group (6.6%).ConclusionThe cost of an episode of care for patients within the bundled payment model is significantly higher for patients undergoing TKA compared with those undergoing a THA. This should be taken into consideration when determining payment plans for patients in alternative payment plans, along with other aspects of risk that need to be considered in order to allow for hospitals to be successful under the bundled payment model.     

Chronic Thrombocytopenia and In-Hospital Outcomes After Primary Total Hip and Knee Arthroplasty

BackgroundThere is a lack of data on the influence of chronic thrombocytopenia (cTCP) on clinical outcomes following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Limited studies mainly focused on postoperative heparin-induced TCP from single centers with small sample sizes. This study aims to describe the characteristics, trend, and outcomes of cTCP in patients undergoing THA and TKA from a nationally reprehensive perspective.MethodsWe identified THA and TKA patients with and without cTCP from the 2005 to 2015 Nationwide Inpatient Sample. Annual percent changes were calculated to reflect cTCP trends. Multivariable regression and propensity score analyses were conducted to investigate the association of cTCP and mortality, preoperative complications, cost as well as length of stay.ResultsIn total, 578,278 and 1,237,331 patients underwent primary THA and TKA, respectively. Proportion of cTCP annually increased by 6.95% in THA and 6.66% in TKA. Patients with cTCP were associated with higher risk of medical (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.89-2.11) and surgical complications (OR 2.72, 95% CI 2.55-2.90) in THA, and higher risk of mortality (OR 1.68, 95% CI 1.22-2.31), medical (OR 1.94, 95% CI 1.85-2.03) and surgical complications (OR 2.55, 95% CI 2.38-2.73) in TKA. Additionally, higher cost and longer length of stay were observed in patients with cTCP for both surgical procedures.ConclusionPatients with cTCP had higher risk of mortality for TKA, more perioperative complications for both TKA and THA. Further studies are warranted to improve the preoperative management and to prevent worse outcomes associated with cTCP.     

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients.MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs.ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001).ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.     

Retained Antibiotic Spacers After Total Hip and Knee Arthroplasty Resections: High Complication Rates

Background

Prolonged retention of an antibiotic spacer is occasionally chosen during treatment of periprosthetic joint infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of our study was to evaluate the outcome of extended spacer retention.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons

BackgroundA survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members.MethodsAn application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns.ResultsThere was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume.ConclusionThis survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.     

From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative improved quality and reduced costs following total hip (THA) and knee arthroplasty (TKA). In October 2018, the BPCI-Advanced program was implemented. The purpose of this study is to compare the quality metrics and performance between our institution’s participation in the BPCI program with the BPCI-Advanced initiative.MethodsWe reviewed a consecutive series of Medicare primary THA and TKA patients. Demographics, medical comorbidities, discharge disposition, readmission, and complication rates were compared between BPCI and BPCI-Advanced groups. Medicare claims data were used to compare episode-of-care costs, target price, and margin per patient between the cohorts.ResultsCompared to BPCI patients (n = 9222), BPCI-Advanced patients (n = 2430) had lower rates of readmission (5.8% vs 3.8%, P = .001) and higher rate of discharge to home (72% vs 78%, P < .001) with similar rates of complications (4% vs 4%, P = .216). Medical comorbidities were similar between groups. BPCI-Advanced patients had higher episode-of-care costs ($22,044 vs $18,440, P < .001) and a higher mean target price ($21,154 vs $20,277, P < .001). BPCI-Advanced patients had a reduced per-patient margin compared to BPCI ($890 loss vs $1459 gain, P < .001), resulting in a $2,138,670 loss in the first three-quarters of program participation.ConclusionDespite marked improvements in quality metrics, our institution suffered a substantial loss through BPCI-Advanced secondary to methodological changes within the program, such as the exclusion of outpatient TKAs, facility-specific target pricing, and the elimination of different risk tracks for institutions. Medicare should consider adjustments to this program to keep surgeons participating in alternative payment models.     

Improving Value in Total Hip and Knee Arthroplasty: The Role of High Volume Hospitals

Background

Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals.

The Association Between Hospital Length of Stay and 90-Day Readmission Risk Within a Total Joint Arthroplasty Bundled Payment Initiative

Background

To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundRecent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.ResultsTwenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.ConclusionED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.     

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty

BackgroundPatient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsWe retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA.ResultsIn total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001).ConclusionWe found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.     

Effect of Risk Acceptance for Bundled Care Payments on Clinical Outcomes in a High-Volume Total Joint Arthroplasty Practice After Implementation of a Standardized Clinical Pathway

Background

The Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities.

Relationships Between Preoperative Mental Health and Improvements in Patient-Reported Outcomes After Total Hip and Knee Arthroplasty

BackgroundPoor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups.MethodsElective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (≥75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoperative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately.ResultsMedian postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA, −4.0 high-THA, and −4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B = −0.94 - −0.68, P < .001-P = .01) but with improvements in joint health only in the low-THA group (B = −0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group.ConclusionPatients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and preoperative counseling.     

Readmission,Reoperation, and Complications: Total Hip vs Total Knee Arthroplasty

Background

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are currently grouped under the same Diagnosis-Related Group (DRG). With the introduction of bundled payments, providers are accountable for all the costs incurred during the episode of care, including the costs of readmissions and management of complications. However, it is unclear whether readmission rates and short-term complications are similar in primary THA and TKA.

Anterior Knee Pain After Total Hip Arthroplasty in Developmental Dysplasia

Little has been reported on knee pain after total hip arthroplasty (THA). The purpose of this study was to investigate the incidence and mechanism of knee pain after THA. Two hundred fifty-two patients with hip dysplasia were clinically and radiographically assessed for knee pain before and after THA. Incidences of knee pain and patellofemoral alignment were analyzed with reference to postoperative change in leg length, femoral anteversion, and the femoral offset. Anterior knee pain was present in 16 patients (7.3%). Lateral patellar tilt was increased in all patients with knee pain and significantly larger compared to that seen in patients without knee pain. The increased patellar tilt disappeared within 3 months, but symptoms in 4 patients persisted for more than 3 months. The patellar tilt was significantly related to the amount of leg lengthening. This study demonstrates that THA influences the patellofemoral joint via leg lengthening and causes anterior knee pain.