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.

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.

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change.

BACKGROUND: The need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change. METHODS: A single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program. RESULTS: Overall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP. CONCLUSION: Comparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.

The "Bundle Busters": Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty.

BACKGROUND: Recently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). METHODS: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. RESULTS: Among 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. CONCLUSION: Joint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.