Arthroplasty, Replacement
Conditions
Brief summary
Bundled payments (BP) are a key part of Medicare's shift away from the traditional fee-for-service (FFS) payment model. The investigators propose to study a nationwide randomized-controlled trial (RCT) of bundled payments for knee and hip replacements that was designed and implemented by CMS and launched in April 2016. Randomization was conducted at the Metropolitan Statistical Area (MSA) level with 67 MSAs and about 800 hospitals assigned to the treatment group. The investigators will examine the impact of bundled payments on Medicare spending, utilization, and quality. Study findings should be directly relevant for the design of payments for knee and hip replacements, two common and expensive medical procedures. Average impacts, as well as variation in impact across types of providers and markets may also shed light on economic mechanisms, which should be relevant for bundled payment initiatives under consideration for other medical services.
Interventions
OTHERBundled payments for knee and hip replacement
The bundled payment model holds acute care hospitals (ACHs) financially responsible for the spending and quality of an entire episode of care for two types of hospital admissions: MS-DRG 469 and 470. An episode begins with an ACH stay that results in a discharge in one of the two DRGs, and ends 90 days after discharge. Before each performance year begins, hospitals receive target prices from CMS, determined by historical hospital and regional episode expenditures. Hospitals are eligible for reconciliation payment from CMS if they spend less than the target prices for an episode, provided that they met an acceptable quality standard. Conversely, they are responsible for paying the difference if they spend more than the target prices.
Sponsors
Harvard University
University of Chicago
Dartmouth College
Amy Finkelstein
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Acute care hospital paid under the inpatient prospective payment system (IPPS) * Hospital admission for major joint replacement or reattachment of lower extremity with and without major complications or comorbidities (MS-DRG 469 and 470)
Exclusion criteria
* MSA
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Share of LEJR admissions discharged to institutional Post-Acute Care (PAC) | At hospital discharge up to 3 days | Share of lower extremity joint replacement (LEJR) index admissions discharged to institutional post-acute care facilities (i.e. skilled nursing facilities (SNF), long term care hospitals (LTCH) or inpatient rehabilitation facilities (IRF)). LEJR index admissions are eligible admissions at acute care hospitals (ACH) that result in a discharge in either DRG 469 or 470. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of days in Institutional PAC during episode | Begins with index admission and ends 90 days post-discharge from index admission | number of days in institutional PAC facilities (sum of length of stays in SNF, LTCH and IRF) |
| Total covered Medicare payments during episode | Begins with index admission and ends 90 days post-discharge from index admission | Total covered Medicare payments are defined as the total amount of Medicare Part A and part B Fee-for-Service (FFS) payments that are included in the bundle. Note that, as defined, total covered Medicare payments are the payments that would be made in the absence of Bundled Payments (i.e. payments that would occur under FFS Medicare). These are counterfactual for the treatment MSAs. If the data become available, the investigators plan to also look at actual payments made during the episode (which would include any reconciliation payments or repayments to or from hospitals in the treatment MSAs). |
| Share of LEJR admissions discharged to any Post Acute Care (PAC) | At hospital discharge up to 3 days | Share of LEJR index admissions discharged to any PAC, which includes Institutional Post Acute Care (SNF, LTCH, IRF) plus home health agency. LEJR index admissions are eligible admissions at acute care hospitals (ACH) that result in a discharge in either DRG 469 or 470. |
| Total covered Medicare payments for any PAC during episode | Begins with index admission and ends 90 days post-discharge from index admission | — |
| Total beneficiary payments owed out of pocket during episode | Begins with index admission and ends 90 days post-discharge from index admission | — |
| Total covered Medicare payments for Institutional PAC during episode | Begins with index admission and ends 90 days post-discharge from index admission | — |
Other
| Measure | Time frame | Description |
|---|---|---|
| 1 year total covered Medicare payments | one year since index admission | — |
| 1 year mortality | one year since index admission | — |
| Complexity of patient mix for LEJR procedures, measured by patient demographics | Duration of hospital stay - average 3 days | The complexity of patient mix for LEJR procedures is measured by the projected episode payment using patient demographics. The investigators will generate projected episode payment based on coefficients from a regression of episode payment on patient demographics in the pre-period, controlling for MSA fixed effect. The set of patient demographics include fully interacted five-year-age-bin, race, and sex dummies, dummy for Medicaid status, and dummy for disability. |
| 1 year outpatient opioid use | one year since index admission | — |
| 1 year all-cause readmission | one year since index admission | — |
| Any THA/TKA complication | Begins with index admission and ends 90 days post-discharge from index admission | The total hip arthroplasty/total knee arthroplasty (THA/TKA) complication measure is a facility-level risk-standardized 90-day complication rate for total hip and total knee arthroplasty and is part of the targeted quality measure. However this component of the targeted quality measure is a three-year moving average. While it may not be feasible to replicate the measure, the investigators will code the underlying the eight complications, which are heart attack, pneumonia, or sepsis/septicemia/shock within seven days of admission, surgical site bleeding, pulmonary embolism, or death within 30 days of admission, and mechanical complications or periprosthetic joint/wound infection within 90 days of admission. The proposed measure is an indicator for whether any of the eight THA/TKA complications occur. |
| Number of THA/TKA complications | Begins with index admission and ends 90 days post-discharge from index admission | The total hip arthroplasty/total knee arthroplasty (THA/TKA) complication measure is a facility-level risk-standardized 90-day complication rate for total hip and total knee arthroplasty and is part of the targeted quality measure. However this component of the targeted quality measure is a three-year moving average. While it may not be feasible to replicate the measure, the investigators will code the underlying the eight complications, which are heart attack, pneumonia, or sepsis/septicemia/shock within seven days of admission, surgical site bleeding, pulmonary embolism, or death within 30 days of admission, and mechanical complications or periprosthetic joint/wound infection within 90 days of admission. The proposed measure is the number of THA/TKA complications that occur. |
| Share of LEJR admissions with an ER visit within 90-days of discharge from index admission | Begins with index admission and ends 90 days post-discharge from index admission | — |
| 90-day all-cause readmission | 90 days post-discharge from index admission | — |
| Number of covered procedures | Duration of hospital stay - average 3 days | — |
| Complexity of patient mix for LEJR procedures, measured by patient demographics and comorbidities | Duration of hospital stay - average 3 days | The complexity of patient mix for LEJR procedures is measured by the projected episode payment using patient characteristic, including both demographic and comorbidity measures. The investigators will generate projected episode payment based on coefficients from a regression of episode payment on patient characteristics in the pre-period, controlling for MSA fixed effect. The set of patient characteristics include fully interacted five-year-age-bin, race, and sex dummies, dummy for Medicaid status, dummy for disability, dummies for Charlson comorbidities, and dummy for major complication or comorbidity (MCC). |
Outcome results
None listed