Cost of Joint Replacement Using Bundled Payment Models

Importance: Medicare launched the mandatory Comprehensive Care for Joint Replacement bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles. Objective: To analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC. Design, Setting, and Participants: This observational study followed 3942 total patients with lower extremity joint replacement at Baptist Health System (BHS), which participated in ACE and BPCI. Exposures: Lower extremity joint replacement surgery under bundled payment at BHS. Main Outcomes and Measures: Average Medicare payments per episode, readmissions, emergency department visits, prolonged length of stay, and hospital savings from changes in internal hospital costs and PAC spending. Results: Overall, 3942 patients (mean SD age, 72. 4 8. 4 years) from BHS were observed. Between July 2008 and June 2015, average Medicare episode expenditures declined 20. 8%, from 26 785 to 21 208 (P <. 001) for 3738 episodes of joint replacement without complications. It declined 13. 8% from 38 537 to 33 216 (P =. 61) for 204 episodes of joint replacement with complications. Readmissions and emergency department visits declined 1. 4% (P =. 14) and 0. 9% (P =. 98), respectively, while episodes with prolonged length of stay decreased 67. 0% (P <. 001). Patient illness severity remained stable. By 2015, 51. 2% of overall hospital savings had come from internal cost reductions and 48. 8% from PAC spending reductions. Reductions in implant costs, down on average 1920. 68 (29%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined 2443. 12 (27%) per case, largely from reductions in inpatient rehabilitation and skilled nursing facility spending but only when bundles included financial responsibility for PAC. Conclusions and Relevance: During a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.