PROJECTABSTRACT Bundledpaymentsprovideafixedreimbursementforservicesrelatedtothetreatmentofaconditionor procedurethroughadefined?episode-of-care?.Basedoncostsavingsreportedfromdemonstrationprojects, MedicarerecentlyinitiatedtheComprehensiveCareforJointReplacementModel(CJR),amandatorybundled paymentforhipandkneejointreplacementin67randomlyselectedpopulationcenters.Whileadvocates suggestthatCJRcouldslowtherateofmedicalspendingandimprovethequalityofpatientcare,itsvaluehas ?notbeendefinitivelyshowninrigorouslytestedandvalidatedstudies?.IfCJRhasvalue(decreasedcostswith similarquality,orimprovedqualitywithreasonablecosts),Medicarecouldexpanditnationwide,fundamentally shiftingthefinancialriskofpatientcareontohospitals. Reimbursementpoliciesaretheprimarystructuralelementofhealthcarethatinfluencespatientoutcomes forjointreplacement.However,littleempiricalinformationisavailableaboutthefullimpactofbundledpayment programs.Specifically,wedonotknowhowtheywill(a)affectpatient-reportedpainandfunctioning;?(b) influencethevolumeofproceduresandpost-dischargeservices;?(c)stimulatehospitals?responsetoimprove value;?(d)generalizetoanationalprogram;?and(e)triggerpotentialunintendedconsequences. Weproposetoanswerthesecriticalquestionsforhipandkneejointreplacementbypursuingthreeaims: 1)TodeterminewhetherCJRreducesepisode-of-carecosts,improvespatientsafety,andincreases procedurevolume;?2)Tocomparepatient-reportedpainandfunctionaloutcomes(pre-versuspost-surgery change)basedonhospitalparticipationinabundledpaymentprogram;?and3)Toidentifytheimplementation strategies(i.e.,improvedclinicalpathways,post-operativecarecoordination,implantstandardization,patient riskmanagement)thatmosteffectivelyimprovevalueunderbundledpaymentprograms. WewilluniquelylinkMedicareclaimswithpatientreportedoutcomesfromtheAHRQ-fundedFunctionand OutcomeResearchforComparativeEffectivenessinTotalJointReplacementregistryandaPatient-Centered OutcomesResearchInstitute(PCORI)-fundedlargepragmaticclinicaltrial,ComparativeEffectivenessof PulmonaryEmbolismPreventionafterHipandKneeReplacement.LeveragingtherandomselectionofCJR participantandnon-participanthospitalswillhelpclarifythefullspectrumofpolicyeffectsduetotheprogram. WewillalsobuildonthesurveyexpertisewithinDartmouth?sAHRQ-sponsoredCenterofExcellenceinhigh performinghealthcaresystemstoidentifythemosteffectiveimplementationstrategiesadoptedbyhospitalsto improvevalueunderbundledpayments. Thefindingsfromthisproposedevaluationwillbeofcriticalinteresttopatients,policymakers,publicand privatepayers,andhospitalsconcernedwithimprovinghealthcareefficiencywithoutjeopardizingquality.

Public Health Relevance

Medicareisstartinganewwaytopayhospitalswhenpatientsreplaceahiporkneejoint.A?bundledpayment? isonechargeforallhealthcareoccurringwithin90daysofwhenajointisreplaced.Wewillstudyhow hospitalsarepreparingforthenewwayofbeingpaid,andhowthechangeaffectspatientsafetyandwell- being.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Project (R01)
Project #
5R01HS024714-03
Application #
9692470
Study Section
Healthcare Effectiveness and Outcomes Research (HEOR)
Program Officer
Hellinger, Fred
Project Start
2017-05-05
Project End
2021-04-30
Budget Start
2019-05-01
Budget End
2020-04-30
Support Year
3
Fiscal Year
2019
Total Cost
Indirect Cost
Name
University of Utah
Department
Orthopedics
Type
Schools of Medicine
DUNS #
009095365
City
Salt Lake City
State
UT
Country
United States
Zip Code
84112
Martin, Brook I; Lurie, Jon D; Farrokhi, Farrokh R et al. (2018) Early Effects of Medicare's Bundled Payment for Care Improvement Program for Lumbar Fusion. Spine (Phila Pa 1976) 43:705-711
Molloy, Ilda B; Martin, Brook I; Moschetti, Wayne E et al. (2017) Effects of the Length of Stay on the Cost of Total Knee and Total Hip Arthroplasty from 2002 to 2013. J Bone Joint Surg Am 99:402-407