Can Prior Episode-of-Care Costs Predict the Future? Identifying High-Cost Outliers for Subsequent Total Hip and Knee Arthroplasty.

BACKGROUND: It remains unknown if a patient's prior episode-of-care (EOC) costs for total hip (THA) or knee (TKA) arthroplasty procedure can be used to predict subsequent costs for future procedures. The purpose of this study is to evaluate whether there is a correlation between the EOC costs for a patient's index and subsequent THA or TKA. METHODS: We reviewed a consecutive series of 11,599 THA and TKA Medicare patients from 2015 to 2019 and identified all patients who underwent a subsequent THA and TKA during the study period. We collected demographics, comorbidities, short-term outcomes, and 90-day EOC claims costs. A multivariate analysis was performed to identify whether prior high-EOC costs were predictive of high costs for the subsequent procedure. RESULTS: Of the 774 patients (6.7%) who underwent a subsequent THA or TKA, there was no difference in readmissions (4% vs 5%, P = .70), rate of discharge to a skilled nursing facility (SNF) (15% vs 15%, P = .89), and mean costs ($18,534 vs $18,532, P = .99) between EOCs. High-cost patients for the initial TKA or THA were more likely to be high cost for subsequent procedure (odds ratio 14.33, P < .01). Repeat high-cost patients were more likely to discharge to an SNF for their first and second EOC compared to normative-cost patients (P < .01). CONCLUSION: High-cost patients for their initial THA or TKA are likely to be high cost for a subsequent procedure, secondary to a high rate of SNF utilization. Efforts to reduce costs in repeat high-cost patients should focus on addressing post-operative needs pre-operatively to facilitate safe discharge home.

Low Incidence of Asymptomatic Positive Patients Detected During Preoperative Testing for Total Joint Arthroplasty During the COVID-19 Pandemic.

INTRODUCTION: Although the pause in elective surgery was necessary to preserve healthcare resources at the height of the novel coronavirus disease 2019 (COVID-19) pandemic, recent data have highlighted the worsening pain, decline in physical activity, and increase in anxiety among cancelled total hip and knee arthroplasty patients. The purpose of this study was to evaluate the effectiveness of our staged reopening protocol and the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among elective arthroplasty patients. METHODS: We identified all elective hip and knee arthroplasty patients who underwent our universal COVID-19 testing protocol during our phased reopening between May 1, 2020, and July 21, 2020, at our institution. We recorded the SARS-CoV-2 test results of each patient along with their demographics, medical comorbidities, and symptoms at the time of testing. We followed each of these positive patients through their rescheduled cases and recorded any complications or potential SARS-CoV-2 healthcare exposures. RESULTS: Of the 2,329 patients, we identified five patients (0.21%) with a reverse transcription-polymerase chain reaction--confirmed SARS-CoV-2 positive test, none with symptoms. All patients were successfully rescheduled and underwent their elective arthroplasty procedure within 6 weeks of their original surgery date. None of these patients experienced a perioperative complication at the time of their rescheduled arthroplasty procedure. No orthopaedic surgeon or staff member caring for these patients reported a positive SARS-CoV-2 test. CONCLUSION: Our phased reopening protocol with universal preoperative virus testing was safe and identified a low incidence of SARS-CoV-2 among asymptomatic, elective arthroplasty patients at our institution. With uncertainty regarding the trajectory of the COVID-19 pandemic, we hope that this research can guide future policy decisions regarding elective surgery.

From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative improved quality and reduced costs following total hip (THA) and knee arthroplasty (TKA). In October 2018, the BPCI-Advanced program was implemented. The purpose of this study is to compare the quality metrics and performance between our institution's participation in the BPCI program with the BPCI-Advanced initiative. METHODS: We reviewed a consecutive series of Medicare primary THA and TKA patients. Demographics, medical comorbidities, discharge disposition, readmission, and complication rates were compared between BPCI and BPCI-Advanced groups. Medicare claims data were used to compare episode-of-care costs, target price, and margin per patient between the cohorts. RESULTS: Compared to BPCI patients (n = 9222), BPCI-Advanced patients (n = 2430) had lower rates of readmission (5.8% vs 3.8%, P = .001) and higher rate of discharge to home (72% vs 78%, P < .001) with similar rates of complications (4% vs 4%, P = .216). Medical comorbidities were similar between groups. BPCI-Advanced patients had higher episode-of-care costs ($22,044 vs $18,440, P < .001) and a higher mean target price ($21,154 vs $20,277, P < .001). BPCI-Advanced patients had a reduced per-patient margin compared to BPCI ($890 loss vs $1459 gain, P < .001), resulting in a $2,138,670 loss in the first three-quarters of program participation. CONCLUSION: Despite marked improvements in quality metrics, our institution suffered a substantial loss through BPCI-Advanced secondary to methodological changes within the program, such as the exclusion of outpatient TKAs, facility-specific target pricing, and the elimination of different risk tracks for institutions. Medicare should consider adjustments to this program to keep surgeons participating in alternative payment models.

Risk Adjustment for Episode-of-Care Costs After Total Joint Arthroplasty: What is the Additional Cost of Individual Comorbidities and Demographics?

INTRODUCTION: Concerns exist regarding the lack of risk adjustment in alternative payment models for patients who may use more resources in an episode of care. The purpose of this study was to quantify the additional costs associated with individual medical comorbidities and demographic variables. METHODS: We reviewed a consecutive series of primary total hip and knee arthroplasty patients at our institution from 2015 to 2016 using claims data from Medicare and a single private insurer. We collected demographic data and medical comorbidities for all patients. To control for confounding variables, we performed a stepwise multivariate regression to determine the independent effect of medical comorbidities and demographics on 90-day episode-of-care costs. RESULTS: Six thousand five hundred thirty-seven consecutive patients were identified (4,835 Medicare and 1,702 private payer patients). The mean 90-day episode-of-care cost for Medicare and private payers was $19,555 and $30,020, respectively. Among Medicare patients, comorbidities that significantly increased episode-of-care costs included heart failure ($3,937, P < 0.001), stroke ($2,604, P = 0.002), renal disease ($2,479, P = 0.004), and diabetes ($1,368, P = 0.002). Demographics that significantly increased costs included age ($221 per year, P < 0.001), body mass index (BMI; $106 per point, P < 0.001), and unmarried marital status ($1896, P < 0.001). Among private payer patients, cardiac disease ($4,765, P = 0.001), BMI ($149 per point, P = 0.004) and age ($119 per year, P = 0.002) were associated with increased costs. DISCUSSION: Providers participating in alternative payment models should be aware of factors (cardiac history, age, and elevated BMI) associated with increased costs. Further study is needed to determine whether risk adjustment in alternative payment models can prevent problems with access to care for these high-risk patients.

Are We at the Bottom? BPCI Programs Now Disincentivize Providers Who Maintain Quality Despite Caring for Increasingly Complex Patients.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative has been successful at reducing Medicare costs after total joint arthroplasty (TJA). Target pricing is based on each institution's historical performance and is periodically reset. The purpose of this study was to examine the performance of our BPCI program accounting for patient complexity, quality, and resource utilization. METHODS: We reviewed a consecutive series of 9195 Medicare patients undergoing primary TJA from 2015 to 2018. Demographics, comorbidities, and readmissions by year were compared. We then examined 90-day episode-of-care costs, changes in target price, and financial margins during the duration of the BPCI program using Medicare claims data. RESULTS: Patients undergoing TJA in 2018 had a higher prevalence of diabetes and cardiac disease (all P < .001) as compared with those in 2015. From 2015 to 2018, there was a decrease in the rate of discharge to rehabilitation facilities (23% vs 14%, P < .001) and length of stay (2.1 vs 1.7 days, P < .001) with no difference in readmissions (6% vs 6%, P = .945). There was a reduction in postacute care costs ($6076 vs $4,890, P < .001) and 90-day episode-of-care costs ($19,954 vs $18,449, P < .001). However, the target price also decreased ($22,280 vs $18,971, P < .001), and the per-patient margin diminished ($2683 vs $522, P < .001). CONCLUSION: Surgeons have maintained quality of care at a reduced cost despite increasing patient complexity. The target price adjustments resulted in declining margins during the course of our BPCI experience. Policy makers should consider changes to target price methodology to encourage participation in these successful cost-saving programs.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty.

BACKGROUND: With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA. METHODS: At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites. RESULTS: Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient. CONCLUSION: Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

Traditional Risk Factors and Logistic Regression Failed to Reliably Predict a "Bundle Buster" After Total Joint Arthroplasty.

BACKGROUND: The purpose of this study was to determine if we could identify patient factors that were predictive of Medicare and privately insured patients being "high-cost." METHODS: Ninety-day episode-of-care insurance company payments along with collected demographics, comorbidities, and readmissions were reviewed for a consecutive series of primary total joint arthroplasty patients from 2015 to 2016 at our institution. High-cost patients were identified by determining those patients above the cutoff, where the cost data became demonstrably nonparametric and both univariate analysis and logistical regressions were performed to identify risk factors that lead to increased costs. Receiver operator curves were created to determine the predictive nature of these risk factors. RESULTS: Univariate analysis showed that high-cost privately insured patients were significantly older, more likely to be readmitted and less likely to be discharged to home (P < .001) whereas high-cost Medicare total knee/total hip arthroplasty patients were more likely to have many of the comorbidities analyzed. Logistical regression did not find any predictive factors for privately insured patients and found that diabetes (OR 1.47 and 1.75, respectively), congestive heart failure (OR 1.94 and 3.46, respectively), cerebrovascular event (OR 2.20 and 2.20, respectively) and rheumatic disease (OR 1.78 and 1.78, respectively) were all predictive of being a high-cost Medicare patient. CONCLUSION: Traditional risk factors for postoperative complications are not reliably associated with increased patient costs after total hip and total knee arthroplasty. Furthermore, the risk factors associated with increased costs vary greatly between privately insured and Medicare-insured patients. Further investigation is necessary to identify cost drivers in this patient subset to preventive higher costs.

A Novel, Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems.

BACKGROUND: In 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA. METHODS: After institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs. RESULTS: Of the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001). CONCLUSION: Even after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.

A Nurse Navigator Program Is Effective in Reducing Episode-of-Care Costs Following Primary Hip and Knee Arthroplasty.

BACKGROUND: Alternative payment models for total hip arthroplasty (THA) and total knee arthroplasty (TKA) have incentivized providers to deliver higher quality care at a lower cost, prompting some institutions to develop formal nurse navigation programs (NNPs). The purpose of this study was to determine whether a NNP for primary THA and TKA resulted in decreased episode-of-care (EOC) costs. METHODS: We reviewed a consecutive series of primary THA and TKA patients from 2015-2016 using claims data from the Centers for Medicare and Medicaid Services and Medicare Advantage patients from a private insurer. Three nurse navigators were hired to guide discharge disposition and home needs. Ninety-day EOC costs were collected before and after implementation of the NNP. To control for confounding variables, we performed a multivariate regression analysis to determine the independent effect of the NNP on EOC costs. RESULTS: During the study period, 5275 patients underwent primary TKA or THA. When compared with patients in the prenavigator group, the NNP group had reduced 90-day EOC costs ($19,116 vs $20,418 for Medicare and $35,378 vs $36,961 for private payer, P < .001 and P < .012, respectively). Controlling for confounding variables in the multivariate analysis, the NNP resulted in a $1575 per Medicare patient (P < .001) and a $1819 per private payer patient cost reduction (P = .005). This translates to a cost savings of at least $5,556,600 per year. CONCLUSION: The implementation of a NNP resulted in a marked reduction in EOC costs following primary THA and TKA. The cost savings significantly outweighs the added expense of the program. Providers participating in alternative payment models should consider using a NNP to provide quality arthroplasty care at a reduced cost.

How Much Does a Readmission Cost the Bundle Following Primary Hip and Knee Arthroplasty?

BACKGROUND: As alternative payment models increase in popularity for total joint arthroplasty (TJA), providers and hospitals now share the financial risk associated with unexpected readmissions. While studies have identified postacute care as a driver for costs in a bundle, the fiscal burden associated with specific causes of readmission is unclear. The purpose of this study is to quantify the additional costs associated with each of the causes of readmission following primary TJA. METHODS: We reviewed a consecutive series of primary TJA patients at our institution from 2015 to 2016 using claims data from the Centers for Medicare and Medicaid Services and Medicare Advantage patients from a single private insurer. We collected demographic data, medical comorbidities, 90-day episode-of-care costs, and readmissions for all patients. Medical records for each readmission were reviewed and classified into 1 of 11 categories. We then compared the mean facility readmission costs, postacute care costs, and overall 90-day episode-of-care costs between the reasons for readmission. RESULTS: Of the 4704 patients, there were 325 readmissions in 286 patients (6.1%), with 50% being readmitted to a different facility than their index surgery hospital. The mean additional cost was $8588 per readmission. Medical reasons accounted for the majority of readmissions (n = 257, 79.1%). However, patients readmitted for revision surgery (n = 68, 20.9%) had the highest mean readmission cost ($15,356, P < .001). Furthermore, readmissions for revision surgery had the highest mean postacute care ($37,207, P = .002) and overall episode-of-care costs ($52,162, P = .003). Risk factors for readmission included age >75 years (odds ratio [OR], 1.85; P < .001), body mass index >35 kg/m2 (OR, 1.63; P = .004), history of congestive heart failure (OR, 2.47; P = .002), diabetes mellitus (OR, 2.0; P < .001), and renal disease (OR, 2.28; P = .005). CONCLUSION: Providers participating in alternative payment models should be cognizant of the increased bundle costs attributed to readmissions, especially due to revision surgery. Improved communication with patients and close postoperative monitoring may help minimize the large percentage of readmissions at different facilities.