Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC.
J Arthroplasty. 2019 Aug;34(8):1581-1584. doi: 10.1016/j.arth.2019.05.016. Epub 2019 May 15.
Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services to decrease overall healthcare cost. The associated shift of financial risk to participating institutions may negatively influence patient selection to avoid high cost of care ("cherry picking," "lemon dropping"). This study evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery, and hospital costs at a single care center.
Patients undergoing a primary THA from 2015-2017 were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before (pre-CJR) or after (post-CJR) CJR bundle implementation. Patient age, gender, and body mass index, Elixhauser comorbidities and American Society of Anesthesiologists scores, were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared pre- and post-CJR.
A total of 751 THA patients (273 Medicare and 478 commercial Insurance) were evaluated pre-CJR (29%) and post-CJR (71%). Patient demographics were similar (age, gender, BMI); however, commercially insured patients had less comorbidities pre-CJR (P = .033). Medicare patient post-CJR length of stay (P = .010) was reduced with a trend toward discharge to home (P = .019). Surgical time, operating room service time, 90-day readmissions and direct hospital costs were similar pre- and post-CJR.
There was no differential patient selection after CJR bundle implementation and value-based metrics (surgical time, operating room service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals.
为降低整体医疗成本，医疗保险和医疗补助服务中心（CMS）启动了全髋关节置换术（THA）的替代支付模式。将财务风险转移给参与机构可能会对患者选择产生负面影响，以避免高护理成本（“择优筛选”，“劣汰”）。本研究评估了综合关节置换护理（CJR）模式对单一护理中心患者选择、护理提供和医院成本的影响。
根据保险类型（医疗保险和商业保险）和护理是否在 CJR 捆绑实施之前（CJR 前）或之后（CJR 后）进行分层，对 2015 年至 2017 年接受初次 THA 的患者进行分析。分析患者年龄、性别和体重指数、Elixhauser 合并症和美国麻醉医师协会评分。比较 CJR 前后手术持续时间、出院去向、住院时间和直接医院费用等护理变量。
共评估了 751 例 THA 患者（273 例医疗保险和 478 例商业保险），CJR 前（29%）和 CJR 后（71%）。患者人口统计学特征相似（年龄、性别、BMI）；然而，商业保险患者 CJR 前合并症较少（P =.033）。CJR 后医疗保险患者的住院时间（P =.010）缩短，出院回家的趋势（P =.019）。CJR 前后手术时间、手术室服务时间、90 天再入院率和直接医院费用相似。
CJR 捆绑实施后，患者选择没有差异，基于价值的指标（手术时间、手术室服务时间）不受影响。患者出院更快，更常出院回家。然而，总体直接医院费用保持不变，表明任何成本节约都是为保险公司，而不是为参与医院。
