Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale. A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation. Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains. The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Zogg CK ，Falvey JR ，Dimick JB ，Haider AH ，Davis KA ，Grauer JN ... -  《-》

Association of Mandatory Bundled Payments for Joint Replacement With Use of Postacute Care Among Medicare Advantage Enrollees.

Meyers DJ ，Kosar CM ，Rahman M ，Mor V ，Trivedi AN ... -  《-》

Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty.

Ponnusamy KE ，Naseer Z ，El Dafrawy MH ，Okafor L ，Alexander C ，Sterling RS ，Khanuja HS ，Skolasky RL ... -  《-》

Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care: Interim Analysis of the First Year of a 5-Year Randomized Trial.

Finkelstein A ，Ji Y ，Mahoney N ，Skinner J ... -  《-》

Unintended Bundled Payments for Care Improvement Consequences After Removal of Total Knee Arthroplasty From Inpatient-Only List.

The Centers for Medicare and Medicaid Services beginning in 2013 introduced the Bundled Payments for Care Improvement (BPCI) initiative to test innovative payment and service delivery models. Early implementers of the BPCI program have shown decreased hospital length of stays, discharges to inpatient facilities, and readmission rates with overall cost savings. Removal of total knee arthroplasty from the Medicare inpatient-only list may potentially cause substantial changes in patients included in BPCI bundles in 2018. The 2017 Centers for Medicare and Medicaid Services data were used to compare total expenditures of diagnosis-related groups 469 and 470. Medicare patients who underwent total knee arthroplasty between January 2017 and December 2017 were defined as group one (n = 1024) and expenditures were compared to group two patients (n = 631) that included only those patients staying greater than 24 hours. Postacute events within the 90-day episode including admission to an inpatient rehabilitation facility/skilled nursing facility (SNF), home health (HH), and readmissions were analyzed. Expenditures were converted to 2018 dollars using Consumer Price Index. Statistical analysis of expenditures was performed with Wilcoxon Tests. Median expenditures were $15,587 (interquartile range [IQR] $13,915-$17,684) for group 1 and $16,706 (IQR $15,333-$19,247) for group 2 (P < .001). Median postacute care spend was $3817 (IQR $2431-$5057) for group 1 and $4195 (IQR $3049-$6064) for group 2 patients (P < .001). Compared with group 1 patients, group 2 patients had a higher rate of SNF admissions (21% vs 13%), inpatient rehabilitation facility admissions (0.16% vs 0.1%), HH (72% vs 69%), and readmissions (5% vs 4%). Implications of the removal of total knee arthroplasty from the inpatient-only list could potentially remove up to 40% of patients from the BPCI program leading to substantially less savings on average $1100 per patient. Remaining bundle patients are also more likely to require HH and SNF after discharge.

Curtin BM ，Odum SM ，OrthoCarolina Quality Improvement Committee 《-》