Skip to main content
Hauptrubriken
CME Facharzt-Training Webinare Zeitschriften Bücher e.Medpedia Podcast
Service
Jobbörse Info & Hilfe
Fachgebiete
Anästhesiologie Allgemeinmedizin Arbeitsmedizin Augenheilkunde Chirurgie Dermatologie Gynäkologie und Geburtshilfe HNO Innere Medizin Kardiologie Neurologie Onkologie und Hämatologie Orthopädie und Unfallchirurgie Pädiatrie Pathologie Psychiatrie Radiologie Rechtsmedizin Urologie Zahnmedizin
Themen
Klimawandel und Gesundheit Neues aus dem Markt COVID-19 Praxis und Beruf Seltene Erkrankungen GOÄ & EBM Panorama
Sammlungen
Kasuistiken Algorithmen & Infografiken Blickdiagnosen Arthropedia FlapFinder (für Dermatochirurgen) Videos Kongressberichterstattung Medizin für Apothekerinnen und Apotheker Für Ärztinnen und Ärzte in Weiterbildung Für Medizinstudierende
Erweiterte Suche
Anmelden
nach oben
Current Reviews in Musculoskeletal Medicine
Erschienen in: Current Reviews in Musculoskeletal Medicine 3/2017

24.07.2017 | Quality and Cost Control in TJA (B Waddell, section editor)

Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality

verfasst von: Alexander S. McLawhorn, Leonard T. Buller

Erschienen in: Current Reviews in Musculoskeletal Medicine | Ausgabe 3/2017

Einloggen, um Zugang zu erhalten

Abstract

Purpose of review

The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA).

Recent findings

From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control.

Summary

Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.
Literatur
1.
Nwachukwu BU, O’Donnell E, McLawhorn AS, et al. Episode of care payments in total joint arthroplasty and cost minimization strategies. HSS J. 2016;12(1):91–3.CrossRefPubMed
2.
3.
Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.PubMed
4.
Cram P, Lu X, Kates SL, et al. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012;308(12):1227–36.CrossRefPubMedPubMedCentral
5.
6.
Daigle ME, Weinstein AM, Katz JN, et al. The cost-effectiveness of total joint arthroplasty: a systematic review of published literature. Best Pract Res Clin Rheumatol. 2012;26(5):649–58.CrossRefPubMed
7.
Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370(9597):1508–19.CrossRefPubMed
8.
Centers for Medicare Medicaid Services. Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Final Rule 2015:1–282.
9.
Hawker GA, Badley EM, Croxford R, et al. A population-based nested case-control study of the costs of hip and knee replacement surgery. Med Care. 2009;47(7):732–41.CrossRefPubMed
10.
Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5):1418–28.CrossRefPubMed
11.
12.
Tomek IM, Sabel AL, Froimson MI, et al. A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Aff (Millwood). 2012;31(6):1329–38.CrossRef
13.
14.
Froimson MI, Rana A, White RE Jr, et al. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplast. 2013;28(8 Suppl):157–65.CrossRef
15.
•• Bozic KJ, Ward L, Vail TP, et al. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472(1):188–93. This study examined Medicare episode-of-care payments for 250 lower extremity TJAs performed at one institution. The authors found wide variance in costs depending on procedure type, patient comorbidities, complications, discharge destination, and readmission. Post-acute care, including use of skilled facilities, accounted for greater than one-third of total episode payments. CrossRefPubMed
16.
• Froemke CC, Wang L, ML DH, et al. Standardizing care and improving quality under a bundled payment initiative for total joint arthroplasty. J Arthroplast. 2015;30(10):1676–82. The authors describe their care pathway and gain-sharing arrangement under a bundled payment pilot program. Comparisons between pre-pilot and pilot cohorts demonstrated an 18% reduction in average length of hospital stay and decreased utilization of home health and skilled care facilities after hospital discharge to home self-care. CrossRef
17.
18.
Lansky D, Nwachukwu BU, Bozic KJ. Using financial incentives to improve value in orthopedics. Clin Orthop Relat Res. 2012;470(4):1027–37.CrossRefPubMed
19.
• Kamath AF, Courtney PM, Bozic KJ, et al. Bundled Payment in Total Joint Care: Survey of AAHKS Membership Attitudes and Experience with Alternative Payment Models. J Arthroplast. 2015;30(12):2045–56. The authors surveyed the American Association of Hip and Knee Surgeons membership about their participation in and attitudes toward alternative payment models (APM). At the time of the survey, 61% of members were planning to participate in or already participating in an APM. 45% of respondents believed that bundled payments would be most effective at improving quality and reduce costs associated with lower extremity arthroplasty. There were concerns about disincentives to provide care to high-risk patients and uncertainty about gain-sharing. CrossRef
20.
Shih T, Chen LM, Nallamothu BK. Will bundled payments change health care? Examining the evidence thus far in cardiovascular care. Circulation. 2015;131(24):2151–8.CrossRefPubMedPubMedCentral
21.
Chulis GS. Assessing Medicare’s prospective payment system for hospitals. Med Care Rev. 1991;48(2):167–206.CrossRefPubMed
22.
White C. Why did Medicare spending growth slow down? Health Aff (Millwood). 2008;27(3):793–802.CrossRef
23.
Feinglass J, Holloway JJ. The initial impact of the Medicare prospective payment system on US health care: a review of the literature. Med Care Rev. 1991;48(1):91–115.CrossRefPubMed
24.
Lave JR. The effect of the Medicare prospective payment system. Annu Rev Public Health. 1989;10:141–61.CrossRefPubMed
25.
26.
27.
National Quality Forum. 1550: Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). STEWARD: Centers for Medicare & Medicaid Services Available at: http://​www.​qualityforum.​org/​QPS/​1550. 1/25/2017;2017(02/07).
28.
National Quality Forum. 1551: Hospital-level 30-day risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). STEWARD: Centers for Medicare & Medicaid Services. Available at: http://​www.​qualityforum.​org/​QPS/​1551. 1/25/2017;2017(02/07).
29.
30.
SooHoo NF, Lieberman JR, Ko CY, et al. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88(3):480–5.PubMed
31.
Ollendorf DA, Vera-Llonch M, Oster G. Cost of venous thromboembolism following major orthopedic surgery in hospitalized patients. Am J Health Syst Pharm. 2002;59(18):1750–4.PubMed
32.
Oster G, Ollendorf DA, Vera-Llonch M, et al. Economic consequences of venous thromboembolism following major orthopedic surgery. Ann Pharmacother. 2004;38(3):377–82.CrossRefPubMed
33.
• Kapadia BH, MJ ME, Issa K, et al. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplast. 2014;29(5):929–32. The authors reviewed an institutional periprosthetic joint infection (PJI) registry to identify total knee PJI treated between 2007 and 2011 with a 2-stage exchange arthroplasty. Twenty one patients with PJI were matched 1:1 with primary TKA patients. PJI patients had significantly longer length of hospital stay, more readmissions, and more outpatient visits. The mean annual cost was $116,383 for the PJI cohort, compared to $28,249 for the primary TKA cohort. CrossRef
34.
Kurtz SM, Lau E, Watson H, et al. Economic burden of periprosthetic joint infection in the United States. J Arthroplast. 2012;27(8 Suppl):61–5. e1CrossRef
35.
• Hustedt JW, Goltzer O, Bohl DD, et al. Calculating the cost and risk of comorbidities in total joint arthroplasty in the United States. J Arthroplast. 2017;32(2):355–361.e1. The authors reviewed the National Inpatient Sample to identify primary and revision hip and knee arthroplasty patients treated between 2008 and 2012. Comorbid conditions were recorded, and their associations with complications and costs were determined. They found that patients with congestive heart failure (CHF), valvular heart disease and chronic obstructive pulmonary disease had the greatest risk for postoperative complications, while patients with coagulopathy, CHF, and electrolyte disorders had the highest cost after total joint arthroplasty. CrossRef
36.
• Keeney JA, Nam D, Johnson SR, et al. Socioeconomically disadvantaged CMS beneficiaries do not benefit from the readmission reduction initiatives. J Arthroplast. 2015;30(12):2082–5. The authors analyzed 3,825 primary total hip arthroplasties and 3,118 primary total knee arthroplasties performed at a single institution, and found that minority patients and those of lower socioeconomic status had higher readmission rates after total knee and hip arthroplasty, despite risk reduction initiatives. CrossRef
37.
• Keeney JA, Nam D, Johnson SR, et al. The impact of risk reduction initiatives on readmission: THA and TKA readmission rates. J Arthroplast. 2015;30(12):2057–60. The authors examined the impact of risk reduction initiatives on 30-day readmissions after primary total knee and total hip arthroplasty at a single institution. They found that these initiatives resulted in a significant reduction in readmission frequency after total knee arthroplasty, but not after total hip arthroplasty. CrossRef
38.
•• Navathe AS, Troxel AB, Liao JM, et al. Cost of joint replacement using bundled payment models. JAMA Intern Med. 2017;177(2):214–22. The authors analyzed 3,942 patients receiving primary hip and knee replacement under the Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Mean episode expenditures declined over 20%, for joint replacement episodes without complications, whereas they declined approximately 14% joint replacement episodes with complications. Readmissions and emergency department visits declined insignificantly. Over 50% of hospital savings came from internal cost reductions, and the balance came from post-acute care spending reductions by reducing skilled care facility utilization. Reductions in implant costs, contributed the most to hospital savings. CrossRefPubMed
39.
• Slover JD, Mullaly KA, Payne A, et al. What is the best strategy to minimize after-care costs for total joint arthroplasty in a bundled payment environment? J Arthroplast. 2016;31(12):2710–3. The authors used decision analysis techniques to explore the feasibility of extending hospital length of stay to avoid discharge to skilled care facilities after lower extremity joint replacement. They found that extending the acute hospitalization for up to 5.2 extra days to permit discharge to home, may be financially preferable over discharge to a skilled care facility. CrossRef
40.
• Fu MC, Samuel AM, Sculco PK, MacLean CH, Padgett DE, McLawhorn AS. Discharge to inpatient facilities after total hip arthroplasty is associated with increased postdischarge morbidity. J Arthroplast. 2017. The authors used the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014 to identiy all primary total hip arthroplasty (THA) patients. They found that discharge to skilled care facilities following THA is associated with increased odds for septic complications, urinary complications, readmission, wound complications, and respiratory complications.
41.
• McLawhorn AS, Fu MC, Schairer WW, Sculco PK, MacLean CH, Padgett DE. Continued inpatient care after primary total knee arthroplasty increases 30-day post-discharge complications: a propensity score-adjusted analysis. J Arthroplast. 2017. The authors used the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014 to identiy all primary total knee arthroplasty (TkA) patients. They found that discharge to skilled care facilities following TKA is associated with increased odds for unplanned hospital readmission, and for respiratory, septic, thromboembolic and urinary complications.
42.
• Buhagiar MA, Naylor JM, Harris IA, Xuan W, Kohler F, Wright R, et al. Effect of inpatient rehabilitation vs a monitored home-based program on mobility in patients with total knee arthroplasty: The HIHO Randomized Clinical Trial. JAMA. 2017;317(10):1037–46. This randomized controlled trial demonstrated that use of skilled care facilities for rehabilitation following total knee arthroplasty did not improve mobility at 26 weeks after surgery compared to patients receiving a monitored home-based program. CrossRefPubMed
43.
Mahomed NN, Davis AM, Hawker G, et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008;90(8):1673–80.CrossRefPubMed
44.
Bosco JA 3rd, Karkenny AJ, Hutzler LH, et al. Cost burden of 30-day readmissions following Medicare total hip and knee arthroplasty. J Arthroplast. 2014;29(5):903–5.CrossRef
45.
Clair AJ, Evangelista PJ, Lajam CM, et al. Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative. J Arthroplast. 2016;31(9):1862–5.CrossRef
46.
Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty? Clin Orthop Relat Res. 2017; doi:10.​1007/​s11999-017-5244-6.
47.
48.
Maradit Kremers H, Visscher SL, Moriarty JP, et al. Determinants of direct medical costs in primary and revision total knee arthroplasty. Clin Orthop Relat Res. 2013;471(1):206–14.CrossRefPubMed
49.
Mercuri JJ, Bosco JA, Iorio R, et al. The ethics of patient cost-sharing for total joint arthroplasty implants. J Bone Joint Surg Am. 2016;98(24):e111.CrossRefPubMed
50.
Robinson JC, Pozen A, Tseng S, et al. Variability in costs associated with total hip and knee replacement implants. J Bone Joint Surg Am. 2012;94(18):1693–8.CrossRefPubMed
51.
Martineau P, Filion KB, Huk OL, et al. Primary hip arthroplasty costs are greater in low-volume than in high-volume Canadian hospitals. Clin Orthop Relat Res. 2005;(437):152–6.
52.
Scranton PE Jr. The cost effectiveness of streamlined care pathways and product standardization in total knee arthroplasty. J Arthroplast. 1999;14(2):182–6.CrossRef
53.
Zuckerman JD, Kummer FJ, Frankel VH. The effectiveness of a hospital-based strategy to reduce the cost of total joint implants. J Bone Joint Surg Am. 1994;76(6):807–11.CrossRefPubMed
54.
Sharkey PF, Sethuraman V, Hozack WJ, et al. Factors influencing choice of implants in total hip arthroplasty and total knee arthroplasty: perspectives of surgeons and patients. J Arthroplast. 1999;14(3):281–7.CrossRef
55.
Schwarzkopf R, Katz JN, Chen SP, et al. Patients’ willingness to contribute to cost of novel implants in total joint arthroplasty. J Arthroplast. 2014;29(9 Suppl):143–6. e4CrossRef
56.
Schwarzkopf R, Sagebin FM, Karia R, et al. Factors influencing patients' willingness to pay for new technologies in hip and knee implants. J Arthroplast. 2013;28(3):390–4.CrossRef
57.
58.
Wilson NA, Schneller ES, Montgomery K, et al. Hip and knee implants: current trends and policy considerations. Health Aff (Millwood). 2008;27(6):1587–98.CrossRef
59.
Kurtz S, Mowat F, Ong K, et al. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487–97.PubMed
60.
Healy WL, Iorio R, Ko J, et al. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg Am. 2002;84-A(3):348–53.CrossRefPubMed
61.
Larsen K, Hansen TB, Thomsen PB, et al. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91(4):761–72.CrossRefPubMed
62.
Larsen K, Hvass KE, Hansen TB, et al. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord. 2008;9:59. doi:10.​1186/​1471-2474-9-59.CrossRefPubMedPubMedCentral
63.
Khan F, Ng L, Gonzalez S, et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2008;(2):CD004957.
64.
• Wilson S, Marx RG, Pan TJ, Lyman S. Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. J Bone Joint Surg Am. 2016;98(20):1683–90. The authors examined a New York State administrative claims database to identify 289,976 patients undergoing primary total knee arthroplasty. They analyzed surgeon procedure volume thresholds at which there were significant differences in 90-day complications and 2-year revision rates, and they analyzed hospital procedure volume thresholds at which there were significant differences in 90-day complications and 90-day mortality. They identified four volume categories for surgeons: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. They also identified four volume categories for hospitals: 0 to 89, 90 to 235, 236 to 644, and ≥645 total knee arthroplasties per year. CrossRefPubMed
65.
•• Dummit LA, Kahvecioglu D, Marrufo G, et al. Association between hospital participation in a medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodes. JAMA. 2016;316(12):1267–78. The authors reviewed the efficacy of Medicare's BPCI iniative during its first 21 months, comparing hospitals within BPCI and hospitals not participating in bundled payment models. Medicare payments significantly declined for lower extremity joint replacement episodes provided in BPCI-participating hospitals, without a significant change in quality outcomes. CrossRefPubMed
66.
67.
Iorio R, Clair AJ, Inneh IA, et al. Early results of Medicare's bundled payment initiative for a 90-day Total joint arthroplasty episode of care. J Arthroplast. 2016;31(2):343–50.CrossRef
68.
69.
• Dundon JM, Bosco J, Slover J, et al. Improvement in total joint replacement quality metrics: year one versus year three of the bundled payments for care improvement initiative. J Bone Joint Surg Am. 2016;98(23):1949–53. The authors compared lower extremity total joint arthroplasty outcomes between the first and third years of participation in Medicare's BPCI program. They found significantly decreased hospital length of stay, decreased frequency of discharge to skilled care facilities, decreased readmissions, and decreased cost per episode of care in the third year compared to the first year. CrossRefPubMed
70.
• Van Citters AD, Fahlman C, Goldmann DA, et al. Developing a pathway for high-value, patient-centered total joint arthroplasty. Clin Orthop Relat Res. 2014;472(5):1619–35. The authors published their development of a clinical care pathway for lower extremity total joint arthroplasty. The pathway spanned 14 months, from the pre-surgical visit to one year after hospital discharge. Creation of the pathway required input from a multidisciplinary team of stakeholders. The care pathway included over 130 techniques to improve care, focusing principally on standardization and process improvement, interdisciplinary collaboration, and patient engagement and education. CrossRefPubMed
Metadaten
Titel
Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality
verfasst von
Alexander S. McLawhorn
Leonard T. Buller
Publikationsdatum
24.07.2017
Verlag
Springer US
Erschienen in
Current Reviews in Musculoskeletal Medicine / Ausgabe 3/2017
Elektronische ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-017-9423-6

Weitere Artikel der Ausgabe 3/2017

Current Reviews in Musculoskeletal Medicine 3/2017 Zur Ausgabe

ACL Rehab (T Sgroi and J Molony, section editors)

Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury

ACL Rehab (T Sgroi and J Molony, section editors)

Non-operative Care of the Patient with an ACL-Deficient Knee

Quality and Cost Control in TJA (B Waddell, section editor)

Current Trends in Discharge Disposition and Post-discharge Care After Total Joint Arthroplasty

Quality and Cost Control in TJA (B Waddell, section editor)

Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty

ACL Rehab (T Sgroi and J Molony, section editors)

Prevention and Management of Post-operative Complications Following ACL Reconstruction

ACL Rehab (T Sgroi and J Molony, section editors)

ACL Rehabilitation Progression: Where Are We Now?

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie. Erweitert durch Fallbeispiele, Videos und Abbildungen. 
» Jetzt entdecken

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Notfall-TEP der Hüfte ist auch bei 90-Jährigen machbar

26.04.2024 Hüft-TEP Nachrichten

Ob bei einer Notfalloperation nach Schenkelhalsfraktur eine Hemiarthroplastik oder eine totale Endoprothese (TEP) eingebaut wird, sollte nicht allein vom Alter der Patientinnen und Patienten abhängen. Auch über 90-Jährige können von der TEP profitieren.

Arthroskopie kann Knieprothese nicht hinauszögern

25.04.2024 Gonarthrose Nachrichten

Ein arthroskopischer Eingriff bei Kniearthrose macht im Hinblick darauf, ob und wann ein Gelenkersatz fällig wird, offenbar keinen Unterschied.

Therapiestart mit Blutdrucksenkern erhöht Frakturrisiko

25.04.2024 Hypertonie Nachrichten

Beginnen ältere Männer im Pflegeheim eine Antihypertensiva-Therapie, dann ist die Frakturrate in den folgenden 30 Tagen mehr als verdoppelt. Besonders häufig stürzen Demenzkranke und Männer, die erstmals Blutdrucksenker nehmen. Dafür spricht eine Analyse unter US-Veteranen.

Ärztliche Empathie hilft gegen Rückenschmerzen

23.04.2024 Leitsymptom Rückenschmerzen Nachrichten

Personen mit chronischen Rückenschmerzen, die von einfühlsamen Ärzten und Ärztinnen betreut werden, berichten über weniger Beschwerden und eine bessere Lebensqualität.

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen
Bildnachweise