Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center

Abstract

Background: Total joint arthroplasty (TJA) remains the highest expenditure in the Centers for Medicare and Medicaid Services (CMS) budget. One model to control cost is the Comprehensive Care for Joint Replacement (CJR) model. There has been no published literature to date examining the efficacy of CJR on value-based outcomes. The purpose of this study was to determine the efficacy and sustainability of a multidisciplinary care redesign for total joint arthroplasty under the CJR paradigm at an academic tertiary care center.

Methods: We implemented a system-wide care redesign, affecting all patients who underwent a total hip or total knee arthroplasty at our academic medical center. The main study outcomes were cost (to CMS), discharge destination, complications and readmissions, and length of stay (LOS); these were measured using the 2017 initial CJR reconciliation report, as well as our institutional database.

Results: The study included 1536 patients (41% Medicare). Per-episode cost to CMS declined by 19.5% to 11% below the CMS-designated national target. Home discharge increased from 62% to 87%. CMS readmissions declined from 15% to 6%; major complications decreased from 2.3% to 1.9%; and LOS declined from 3.6 to 2.1 days.

Conclusions: A mandatory episode-based bundled-payment program can induce favorable changes to value-based metrics, improving quality and outcomes for health-care consumers. Quality and value were improved in this study, evidenced by lower 90-day episode cost, more home discharges, lower readmissions and complications, and shorter LOS. This approach has implications not just for CMS, but for private payers, corporate health programs, and fixed-budget health-care models.

Keywords: Care pathway redesign; Comprehensive care for Joint Replacement (CJR) model; Total hip and knee arthroplasty; Value-based care.

Figure 1

Average length of stay, by month, during the study period. The initial 12-month baseline period, the pilot period of 3 months, and the study period are identified.

Figure 2

Discharge disposition by location. The baseline, pilot, and study period are identified. SNF, skilled nursing facility.