There are many more “types” of diabetes than the pathophysiologic designations of Type 1 and Type 2. In the December 16, 2020 issue of The Journal of Bone & Joint Surgery, Na et al. delineate 4 different diabetes categories and determine their impact on 90-day complications and readmission rates after elective total joint arthroplasty (TJA) among Medicare patients. One premise for this investigation was that, although diabetes is a known risk factor for arthroplasty complications, alternative payment models such as the federally run Comprehensive Care for Joint Replacement (CJR) program adjust their payments only in diabetes cases where the comorbidity is coded as severe.
The authors stratified diabetes into 4 groups as follows:
- No diabetes
- Controlled-uncomplicated diabetes
- Controlled-complicated diabetes
- Uncontrolled diabetes
Among the >500,000 total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) analyzed, the authors found the following when comparing data from the 3 diabetes groups with the no-diabetes group:
- The odds of TKA complications were significantly higher for those with uncontrolled diabetes (odds ratio [OR] = 1.29).
- The odds of THA complications were significantly higher for those with controlled-complicated diabetes (OR = 1.45).
- The odds of readmission were significantly higher in all diabetes groups for both TKA (ORs = 1.21 to 1.48) and THA (ORs = 1.20 to 1.70).
The authors come to 3 basic conclusions based on these findings:
- The odds of hospital readmission and complications following an elective TKA or THA are increased for Medicare beneficiaries who have diabetes.
- It would be reasonable to defer arthroplasty surgery for those with uncontrolled diabetes to allow them to achieve glycemic control.
- The Centers for Medicare & Medicaid Services should include less-severe diabetes and associated systemic complications in alternative-payment model adjustments.
Click here for an “Author Insight” video about this study from co-author Annalisa Na, PhD, DPT.
Wide variability in the cost and quality of health care in the US has led some to describe our system as “uniquely inefficient.” Consequently, we continue to study variability intensely, especially in the realm of joint arthroplasty. In the June 3, 2020 issue of The Journal, Schilling et al. elegantly analyze the variations in 90-day episode payments made by Medicare Part A for total knee arthroplasty (TKA) from 2014 to 2016. In so doing, they provide a snapshot of hospital cost performance and, just as importantly, they offer a methodology by which to measure future hospital-level cost performance with this very popular surgery.
The authors reviewed >700,000 TKAs in the Medicare population at a time prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model, and they ranked >3,200 hospitals within 9 US regions to determine cost performance. Schilling et al. found that during those 3 years, the mean Medicare episode payment for TKA decreased significantly, due almost entirely to a >$1,500 per-case decrease in post-acute care payments, which included lower costs for skilled nursing facilities and inpatient rehabilitation. Also decreasing during that same period were length of hospital stay and 90-day readmission rates.
These findings highlight the improvements in care and cost efficiency that were occurring even before implementation of the CJR. In a Commentary on this study, Susan Odum, PhD suggests that “the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI [Bundled Payments for Care Improvement] program,” an alternative payment model that Medicare rolled out beginning in 2013.
On the other hand, the authors also reveal a persistently high degree of variability in episode payments and resource utilization both across and within geographic regions. This strongly suggests the possibility of further improvement. Regardless of which, if any, alternative payment model we participate in, everyone in the orthopaedic community should think about how to become more efficient in our delivery of musculoskeletal care. And this study provides a conceptual framework and benchmarks for identifying where the room for improvement is.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Many people predicted that the mandatory “bundling” of payments for knee and hip arthroplasty by the Centers for Medicare and Medicaid Services (CMS) that began on April 1, 2016 in several US metropolitan areas would lead to “cherry-picking” and ”lemon-dropping.” In other words, hospitals and surgeons wouldn’t take on more complex and sicker patients for joint replacement for fear that the bundled payment would be insufficient (lemon-dropping), and would instead select the healthier patients (cherry-picking). See related OrthoBuzz post.
In the February 19, 2020 issue of The Journal, Humbyrd et al. compare the characteristics of patients who underwent hip and knee replacement (HKR) from April to December 2015 with those of HKR patients during the same period in 2016, after CMS mandated the bundled-payment program in 67 metropolitan statistical areas (MSAs). The patients were matched so that those treated in bundled and non-bundled settings had similar socioeconomic backgrounds.
The matched groups included 12,388 HKR episodes in 40 bundled MSAs and 20,288 HKRs in 115 nonbundled MSAs. The authors also evaluated pre- and post-policy case-mix changes among 1,549 hip hemiarthroplasties, which are not subject to bundling, in the bundled MSAs.
Among patients who underwent HKR, Humbyrd et al. found no significant differences in patient characteristics—including race, dual Medicare-Medicaid eligibility, tobacco use, obesity, diabetes, and Charlson Comorbidity Index (CCI)—after the bundled-payment policy was implemented. Also, they found that patients in bundled MSAs undergoing hemiarthroplasty had significantly higher CCI values and were more likely to have diabetes than those who underwent HKR. This suggests that some surgeons opt for hemiarthroplasty over total hip replacement in less-healthy patients to avoid treating such patients under a bundled program.
From the MSA perspective, these results suggest that cherry picking and lemon dropping are not occurring in the short term. But we would do well as a profession to ensure that those controversial patient-selection practices are not happening at the individual surgeon level, and that the short-term results demonstrated here by Humbyrd et al. persist over the longer term. Even our sickest joint replacement patients deserve the best surgical care.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
When Medicare’s Comprehensive Care for Joint Replacement (CJR) program was implemented in 2016, the health care community—especially orthopaedic surgeons— had 2 major concerns. First, would the program actually demonstrate the ability to decrease the costs of total joint replacements while maintaining the same, or improved, outcomes? Second, would CJR promote the unintended consequence of participating hospitals and surgeons ”cherry picking” lower-risk patients and steering clear of higher-risk (and presumably higher cost) patients? Both of these questions were at the heart of the study by Barnett et al. in a recent issue of the New England Journal of Medicine.
The authors evaluated hip and knee replacements at 75 metropolitan centers that were mandated to participate in the CJR program and compared the costs, complication rates, and patient demographics to similar procedures at 121 control centers that did not participate in CJR. The authors found significantly greater decreases in institutional spending per joint-replacement episode in institutions participating in the CJR compared to those that did not. Most of these savings appeared to come from CJR-participating institutions sending fewer patients to post-acute care facilities after surgery. Furthermore, the authors did not find differences between centers participating in the CJR and control centers in terms of composite complication rate or the percentage of procedures that were performed on high-risk patients.
While this 2-year evaluation does not provide the level of detail necessary to make far-reaching conclusions, it does address two of the biggest concerns related to CJR implementation from a health-systems perspective. There may be individual CJR-participating centers that are not saving Medicare money or that are cherry picking lower-risk patients, but overall the program appears to be doing what it set out to do—successfully motivating participating hospitals and healthcare facilities to look critically at what they can do to decrease the costs of a joint-replacement episode while simultaneously maintaining a high level of patient care. The Trump administration shifted CJR to a partly voluntary model in March 2018, and I hope policymakers consider these findings if further changes to the CJR model are planned.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Are you confused and frustrated by Medicare’s Quality-Incentive Programs, such as the Merit Based Incentive Payment System (MIPS), Comprehensive Care for Joint Replacement (CJR) program, and the Surgical Hip and Femur Fracture Treatment (SHFFT) model? If so, this webinar is for you.
On Tuesday, August 15, 2017 at 8:00 PM EDT, The Journal of Bone & Joint Surgery (JBJS) and the American Orthopaedic Association (AOA) will host a complimentary LIVE webinar featuring the following speakers and topics:
- Brian McCardel, MD will discuss choosing MIPS-related quality measures, improving performance on those measures, and qualifying for bonuses.
- Thomas Barber, MD, FAOA will focus on managing clinical care including how to deliver low-cost high-quality care for high-risk orthopaedic patients.
- Alexandra Page, MD will discuss partnering with hospitals and post-acute organizations to improve patient care and reap financial rewards.
Moderated by Douglas Lundy, MD, FAOA, the webinar will include a live Q&A session between the audience and panelists.
OrthoBuzz occasionally receives posts from guest bloggers. This “guest post” comes from Richard S. Yoon, MD and Alexander McLawhorn, MD, MBA.
Starting on April 1, 2016, Medicare will implement its Comprehensive Care for Joint Replacement (CJR) model in about 800 hospitals in 67 metropolitan areas around the United States. Finalized in November 2015, the CJR initiative is intended to enhance value for patients undergoing lower extremity joint replacement (LEJR) by motivating institutions to achieve quality improvement via cost control. (For a complete discussion of “value” in orthopaedics, see “Measuring Value in Orthopaedic Surgery” in JBJS Reviews.)
Medicare hopes CJR will promote standardized, coordinated care that takes each LEJR patient seamlessly through an “episode of care” that maximizes outcomes at a reduced cost. Episodes are triggered by hospital admission and are limited to admissions resulting in a discharge paid under MS-DRG 469 or 470. For CJR purposes, episodes last for 90 days following discharge.
Initially, episode target prices will be based on historical hospital-specific reimbursements, but over time, the target prices will increasingly reflect regional averages. If a hospital’s average LEJR episode cost is below the target price, it can receive a “bonus” from CMS. If its average cost is above the target price, it will owe CMS the difference. CMS has designed a gradual rollout plan to mitigate downside risk in the first year and provide current and future participants adequate time to implement evidence-based, cost-effective care and other quality programs in their institutions.
Richard Iorio, MD, chief of adult reconstruction at NYU-Langone Medical Center’s Department of Orthopaedic Surgery, says, “There will be definite winners and losers in CJR. Once geographic pricing becomes the dominant metric for target prices, there will be intense price competition in geographic areas and potential access problems for high risk patients.” At the moment, CJR stratifies risk based only on MS-DRG code and whether a patient has a hip fracture. Unless a more robust risk stratification method is implemented, “cherry-picking” patients may become a significant issue. (See related OrthoBuzz post “Tool for Pre-TJA Risk Stratification.”)
If you are an orthopaedic surgeon who performs LEJR, ask your department head or health system about CJR, because strategies that minimize cost and maximize quality may vary from hospital to hospital. Alignment of hospitals and surgeons is probably the most critical success factor with CJR. To that end, gainsharing— a key component of well-functioning hospital-surgeon partnerships within any bundled-payment environment —for individual orthopaedic surgeons is specifically allowed within the CJR final rule.
Click here for more information, including FAQs and a list of participating areas.
Richard S Yoon, MD is executive chief resident at the NYU Hospital for Joint Diseases.
Alexander McLawhorn, MD, MBA is an arthroplasty fellow at the Hospital for Special Surgery.