Introduction. Bundled budgeting of payments for joint replacement services has become increasing common in an effort to improve quality while lowering cost. In the US, some Medicare bundled payment programs are voluntary whereas some now are mandatory. Large medical care and medical management organizations have largely been assigned or seized control of management of these programs, leaving the surgeon in a subordinate role. The current abstract describes an experience where surgeons provide leadership and accept responsibility in bundled payment program. Methods. We engaged a collective of 16 different private company orthopedic physician groups to apply to become episode initiators under under the Medicare Bundled Payment for Care Improvement (BPCI) models 2 and 3. The application process itself provided historical. cost data, enabling each group to independently decide whether or not to proceed with the BPCI. Results. Ultimately, 7 of the private orthopedic groups decided to continue with the BPCI initiative. At the first quarter reconciliation, savings ranged from 9% to 17% across the participating groups. Conclusion. It is possible and potentially preferable for surgeons to take a primary role in accepting responsibility and leadership in the comprehensive care of joint replacement patients. The surgeons are those who determine the indications for and perform the surgery, accept much of the risk, and typically maintain a career long relationship with the patient. As such, the surgeon is also in the best position to achieve the ultimate goals of improved quality which simultaneously controlling cost. Our experience thus far supports that view that the more leadership surgeons provide in value base care provision, the more our patients and health care system will benefit from optimization of care delivery

Background

Total knee arthroplasty (TKA) overall is a very reliable, durable procedure. Biomechanical studies have suggested superior stress distribution in metal-backed tibial trays, however, these results have not been universally observed clinically. Currently, there is a paucity of information examining the survival and outcomes of all-polyethylene tibial components.

As healthcare spending continues to outpace economic growth, legislators and healthcare economists have explored many processes aimed at improving efficiency and reducing waste within a bundled care environment. Gainsharing or the general concept that organizations and their employees can work together to continually improve outcomes at reduced expenditures in exchange for a portion of the savings has been shown to be effective within the healthcare system. Although gainsharing principles may be applicable to healthcare organizations and their physician partners, specific parameters should be followed when implementing these arrangements. This talk will discuss gainsharing strategies aimed at properly aligning healthcare organizations and physicians, which, if followed, will ensure the successful implementation of gainsharing initiatives.

The high and ever increasing cost of medical care worldwide has driven a trend toward new payment models. Event based models (such as bundled payment for surgical events) have shown a greater potential for care and cost improvement than population-based models (such as accountable care organizations). Since joint replacement is among the most frequent and costly surgical events in medicine, bundled payments for joint replacement episodes have been at the forefront of evolution from fee-for-service to value-based care models and episode-based healthcare reform in general.

Our education as surgeons in medical school, residency, fellowship, and in continuing education has been almost entirely non-economic in focus. Yet, we surgeons are now evolving from being primarily responsive for our patients' medical care to being also responsible for all expenditures associated with our patients' care. Similarly, while the cost of our patients' care was not even available to us, every dollar of expenditure for a patient's episode of care is now available to us in some circumstances. For example, a typical primary joint replacement episode may cost $30,000 for a patient insured by Medicare in the US. A surgeon performing 400 joint replacements per year is therefore authorizing upwards of $12M a year in health care spending by making the decisions to perform reconstructive procedures on those patients.

The risk for value-based surgical episodes of care can be born by various entities including hospital systems or the surgeons themselves. Recent evidence demonstrates that quality improves and cost decreases more rapidly when surgeons take primary responsibility and risk for episodes of care as compared to when a hospital system or third party takes primary responsibility and risk. Yet, as surgeons, our education in the field of medical economics, value-based episodes of care, and payment reform is only just beginning. The more we understand about the cost and value of the services that we order for our patients, the more leadership can provide as healthcare evolves. The current presentation will describe the specific cost of care for the primary joint replacement patient preliminary experience with accepting risk and responsibility for these patients. It is likely that our patients will be best served if we surgeons provide as much leadership as possible in their care, both medically and economically.

Introduction

Patient-reported outcome (PRO) data are variably collected before and after total hip/knee arthroplasty (THA/TKA). We assessed the generalizability of incentivized, prospectively collected PRO data for THA/TKA patient-reported outcome performance measure (PRO-PM) development.

Aims. There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service. Methods. Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020. Results. At its peak in July 2015, 342 acute care hospitals and physician groups participated in Lower Extremity Joint Replacement (LEJR) in BPCI Classic. At its peak in March 2019, 534 acute care hospitals and physician groups participated in LEJR in BPCI Advanced. In January 2020, only 14.5% of legacy hospitals and physician groups opted to stay in BPCI Advanced for LEJR. Analysis of Target Price factors by legacy hospitals during both programmes demonstrates that participants in BPCI Classic received larger negative adjustments on the Target Price than non-legacy hospitals. Conclusion. BPCI Advanced provides little opportunity for a reduction in cost to offset a reduced Target Price for efficient providers, as made evident by the 85.5% withdrawal rate for BPCI Advanced. Efficient providers in BPCI Advanced are challenged by the programme’s application of trend and efficiency factors that presumes their cost reduction can continue to decline at the same rate as non-efficient providers. It remains to be seen if reverting back to Medicare fee for service will support the same level of care and quality achieved in historical bundled payment programmes. Cite this article: Bone Joint J 2021;103-B(6 Supple A):119–125

Episodic, or bundled payments, is a concept now familiar to most in the healthcare arena, but the models are often misunderstood. Under a traditional fee-for-service model, each provider bills separately for their services which creates financial incentives to maximise volumes. Under a bundled payment, a single entity, often referred to as a convener (maybe the hospital, the physician group, or a third party) assumes the risk through a payer contract for all services provided within a defined episode of care, and receives a single (bundled) payment for all services provided for that episode. The time frame around the intervention is variable, but defined in advance, as are included and excluded costs. Timing of the actual payment in a bundle may either be before the episode occurs (prospective payment model), or after the end of the episode through a reconciliation (retrospective payment model). In either case, the defined costs over the defined time frame are borne by the convener.

Cite this article: Bone Joint J 2017;99-B:1280–5.

Aims

The aim of this study was to investigate the differences in 30-day outcomes between patients undergoing revision for an infected total hip arthroplasty (THA) compared with an aseptic revision THA.

Aims

The aim of this study was to compare the rate of perioperative complications following aseptic revision total hip arthroplasty (THA) in patients aged ≥ 80 years with that in those aged < 80 years, and to identify risk factors for the incidence of serious adverse events in those aged ≥ 80 years using a large validated national database.

Aims. Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs. Methods. The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs. Results. A total of 9,263 patients (DRG-466 = 838, DRG-467 = 4,573, and DRG-468 = 3,842) undergoing revision TJA from 2008 to 2014 were included in the study. Undergoing revision for a dislocation (+$1,221), periprosthetic fracture (+$4,454), and prosthetic joint infection (+$5,268) were associated with higher 90-day costs. Among comorbidities, malnutrition (+$10,927), chronic liver disease (+$3,894), congestive heart failure (+$3,292), anaemia (+$3,149), and coagulopathy (+$2,997) had the highest marginal cost-increase. The five US states with the highest 90-day costs were Alaska (+$14,751), Maryland (+$13,343), New York (+$7,428), Nevada (+$6,775), and California (+$6,731). Conclusion. Under the proposed DRG-based bundled payment methodology, surgeons would be reimbursed the same amount of money for revision TJAs, regardless of the indication (periprosthetic fracture, prosthetic joint infection, mechanical loosening) and/or patient complexity. Cite this article: Bone Joint J 2020;102-B(7):959–964

Background. Cementless femoral fixation in total hip arthroplasty (THA) continues to rise worldwide, accompanied by the increasing abandonment of cemented femoral fixation. Cementless fixation is known to contribute to higher rates of post-operative complications and reoperations. New data is available from the Centers for Medicare and Medicaid Services (CMS) regarding total costs of care from the Bundled Payment for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) initiatives. Questions/purposes. How does femoral fixation affect (1) 90-day costs; (2) readmission rates; (3) re-operation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing elective or non-elective THA?. Methods. We performed a retrospective review of 1671 primary THA cases in Medicare patients across nine hospitals in an academic healthcare network. CMS data was used to evaluate lump costs including the surgical admission and 30-day or 90-day post-operative episodes. Costs were then correlated with clinical outcome measures from review of our electronic medical record. Demographic differences were present between the cemented and cementless cohorts. Statistical analyses were performed including multiple regression models adjusted for the baseline cohort differences. Results. After controlling for confounding variables, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented femoral fixation also demonstrated a trend towards lower costs, fewer readmissions and shorter LOS. All of the reoperations within the early postoperative period occurred in cementless patients. Conclusion. In a large Medicare population, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperations. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation. Orthopaedic surgeons in training should become competent with femoral cementation technique

Introduction. The Comprehensive Care for Joint Replacement (CJR) initiative was implemented to address the two most commonly billed inpatient surgical procedures, total hip and knee arthroplasty. The primary purpose of this manuscript is to review the economic implications of one institution's mandatory involvement in CJR in comparison to prior involvement in Bundled Payment for Care Improvement (BPCI). Methods. The average cost per episode of care (EOC) was calculated using our institution's historical data. The target prices, projected savings or losses per EOC, and the projected annual savings for both BPCI and CJR were established and comparatively analyzed. Results. The CJR target prices will decrease in comparison to BPCI target prices by: 24% for MS-DRG 469 without fracture, 22.8% for 469 with fracture, 26.1% for 470 without fracture, 27.7% for 470 with fracture; resulting in a reduction in savings per EOC by: 92.8% for MS-DRG 469 without fracture, 166.0% for 469 with fracture, 94.9% for 470 without fracture, 61.7% for 470 with fracture (Table 1). This institution's projected annual savings under CJR will decrease by 83.3%. Conclusion. These results suggest that the margin for savings in CJR will be substantially reduced compared to those in BPCI. Hospitals resources previously devoted will have far less impact in CJR and hospitals new to CJR who have not made these investments previously, will require even greater resources for developing cost-reduction and quality control strategies to remain financially solvent. The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. For any tables or figures, please contact the authors directly

Introduction. Current CMS reimbursement policy for total joint replacement is aligned with more cost effective, higher quality care. Upon implementation of a standardized evidenced-based care pathway, we evaluated overall procedural costs and clinical outcomes over the 90-day episode of care period for patients undergoing TKA with either conventional (Conv.) or robotic-assisted (RAS) instrumentation. Methods. In a retrospective review of the first seven consecutive quarters of Bundled Payment for Care Improvement (BPCI) Model 2 participation beginning January 2014, we compared 90-day readmission rates, Length of Stay (LOS), discharge disposition, gains per episode in relation to target prices and overall episode costs for surgeons who performed either RAS-TKA (3 surgeons, 147 patients) or Conv. TKA (3 surgeons, 85 patients) at a single institution. All Medicare patients from all surgeons performing more than two TKA's within the study period were included. An evidence-based clinical care pathway was implemented prior to the start of the study that standardized pre-operative patient education, anesthesia, pain management, blood management, and physical/occupational therapy throughout the LOS for all patients. Physician specific target prices were established from institutional historical payment data over a prior three year period. Results. RAS and Conv-TKA procedures exhibited an average gain per episode of $7,600 and $5,579, respectively. The average total cost per 90-day episode was $2,085 lower for patients receiving RAS-TKA ($28,943 versus $31,028), with the majority of cost savings in reduced SNF usage ($1,481) and readmissions ($944). Discharge to home versus Sub-acute Rehabilitation Facilities (SAR's) was 14% higher in the RAS group (62% vs 48%, p<0.05). Conclusions. Implementation of a standardized care pathway across all service departments and physicians resulted in a reduction in overall episode of care costs, with further reductions in cost and discharge to SARs observed with the use of RAS

Introduction. While total hip arthroplasty is considered to be one of the most cost-effective medical interventions, the total cost of care for a population patients treated by THR can present a significant burden on the payer, whether it be an employer, private insurer or government. Data on the true cost of care has rarely been made available to the treating physician. Such lack of information makes comprehensive management difficult. Bundled payment models of care require knowledge of all costs associated with the care of our patients and opens new opportunity for analysis to improve management and outcomes. The current study assess the influence of surgical technique on total cost of care for total hip arthroplasty. Methods. Payment data for 341 patients who underwent total hip arthroplasty at a single institution from June 1. st. , 2011 to October 31. st. , 2014 were analyzed. Each procedure was performed using either the superior, anterior, or posterior exposure. The superior exposure was performed with femoral head excision and without dislocation of the hip. The data were analyzed for total cost, inpatient cost, inpatient physician cost, readmission cost, skilled nursing facility cost, and home healthcare agency cost among the different approaches. Results. The superior hip approach for total hip arthroplasty results in a significant total cost savings over a 90-day episode of care when compared to both the anterior and posterior exposure techniques. It reduced overall costs by approximately $2,000 and $7,000 per case versus the other groups respectively. The superior approach also demonstrated savings in inpatient and skilled nursing facility cost when compared to the other groups. Conclusions. Surgical technique can have a profound influence on the total cost of care for hip arthroplasty patients. The current study demonstrates that the posterior exposure resulted in the largest consumption of resources post-operatively as measured by total cost of care and that the superior exposure resulted in the least consumption of resources among the three surgical exposures assessed. The study suggests that while we focus on many aspects of improvement in the overall episode of care for our patients, that focus on surgical technique may be worthwhile