Abstract
Introduction
Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services (CMS) have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center.
Methods
This is a retrospective review of primary TKA patients from July 2015-December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and BMI were collected in addition to Elixhauser comorbidities and ASA score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care.
Results
1,248 TKA patients (546 Medicare and 702 Commercial Insurance) were evaluated, with 27.0% undergoing surgery prior to the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or BMI. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (p<0.001), prolonged length of stay (p<0.001), and greater discharges to inpatient facilities (p=0.019). There was no significant difference in direct hospital costs or operative service time comparing pre and post bundle patients.
Conclusions
Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by CMS.
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