Spillover effects of mandatory hip and knee replacement surgery bundles in medicare.

BACKGROUND

Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking.

OBJECTIVE

To evaluate the association between CJR participation and changes in outcomes among privately insured individuals.

DESIGN, SETTING, PARTICIPANTS: We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes.

MAIN OUTCOMES AND MEASURES

Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions).

RESULTS

Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses.

CONCLUSIONS

There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.