Alternative Payment Models in Total Joint Arthroplasty: An Orthopaedic Surgeon's Perspective on Performance and Logistics

Are Commercial Value-Based Care Programs Still Viable for Hip and Knee Arthroplasty: An Analysis of a Single Institution

BACKGROUND

Unlike Medicare bundled payment programs for total hip arthroplasty and total knee arthroplasty, which have little variance in facility reimbursements, few publications have studied value-based care (VBC) partnerships with commercial insurers. Specifically, VBC partnerships incentivize practices to maximize revenue surpluses by providing high-value care at decreased costs. Surgical facility choice can reduce costs with more procedures shifting to lower-cost specialty hospitals and ambulatory surgery centers. This study aimed to determine whether demand matching appropriate patients to lower-cost facilities reduced costs in our commercial VBC program.

METHODS

We reviewed a consecutive series of 4,285 primary total hip arthroplasty and total knee arthroplasty patients between January 2020 and April 2023 as part of a single-payer VBC program, including both commercial and Medicare Advantage (MA) plans. Demographics, facility, and 90-day episode-of-care claims data were collected from our clinical and payor cost databases. Surgical facility utilization, total costs, and revenue surpluses were stratified by insurance type (commercial versus MA), and trends were compared over the 4-year study period. There were 1,369 patients (32%) who had MA and 2,916 (68%) who had commercial insurance.

RESULTS

Among commercially insured patients, the mean total ($33,455 versus $27,433, P < 0.001) and facility costs ($25,068 versus $18,385, P < 0.001) both declined from 2020 to 2023, whereas the revenue surpluses ($6,216 versus $13,090, P < 0.001) increased. Among MA patients, mean total ($17,809 versus $17,235, P < 0.001) and facility costs ($13,491 versus $13,151, P < 0.001) had only minimal decreases, whereas revenue surpluses declined ($7,928 versus $4,073, P < 0.001). Utilization of ambulatory surgery centers increased among both groups from 2020 to 2023 (1 versus 20% for commercial, 0.3 versus 12% for MA, P < 0.001).

CONCLUSIONS

Practices can still have successful VBC partnerships with private insurers by demand matching appropriate patients to lower-cost facilities. Our cost-reduction efforts did not have the same success with MA plans. Further studies should evaluate whether continued cuts to MA programs will threaten access.

Declining Medicare reimbursement in spinal imaging: a 15-year review

OBJECTIVE

To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures.

MATERIALS AND METHODS

The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared.

RESULTS

After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of - 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at - 72.6%, whereas x-ray imaging had the smallest decline at - 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97.

CONCLUSION

From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks.

Quality indicators in primary elective total hip and knee arthroplasty

PURPOSE

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation.

METHODS

A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained.

RESULTS

Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia.

CONCLUSION

This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Bundled Care in Elective Total Joint Replacement: Payment Models in Sweden, Canada, and the United States: A Critical Analysis Review

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Rising health-care expenditures and payer dissatisfaction with traditional models of reimbursement have driven an interest in alternative payment model initiatives.

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Bundled payments, an alternative payment model, have been introduced for total joint replacement in Sweden, the United States, and Canada to help to curb costs, with varying degrees of success.

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Outpatient total knee arthroplasty and total hip arthroplasty are becoming increasingly common and provide value for patients and payers, but have negatively impacted providers participating in bundled payment models due to considerable losses and decreased reimbursement.

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A fine balance exists between achieving cost savings for payers and enticing participation by providers in bundled payment models.

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The design of each model is key to payer, provider, and patient satisfaction and should feature comprehensive coverage for a full cycle of care whether it is in the inpatient or outpatient setting, is linked to quality and patient-reported outcomes, features appropriate risk adjustment, and sets limits on responsibility for unrelated complications and extreme outlier events.

Machine Learning With Electronic Health Record Data Outperforms a Risk Assessment Prediction Tool in Predicting Discharge Disposition After Total Joint Arthroplasty

The Risk Assessment Prediction Tool (RAPT) predicts discharge disposition after total joint arthroplasty with only 75% accuracy. The goal of this study was to evaluate whether higher accuracy can be achieved with basic electronic health record (EHR) data combined with machine learning (ML) algorithms. Three ML analysis models were developed: model 1 (M1) evaluated the accuracy of predicted discharge disposition in concordance with the RAPT; model 2 (M2) used the RAPT questionnaire to develop an ML algorithm to predict the likelihood of discharge to home vs facility; and model 3 (M3) was developed with non-RAPT data (age, surgeon, and discharge preference) with the same ML training process as M2. Evaluation metrics included accuracy for home discharge (HD), positive predictive value for HD (PPV-HD), negative predictive value for HD (NPV-HD), sensitivity, specificity, and area under the receiver operating curve (AUROC). A total of 1405 patients were included. With M1, the overall accuracy for HD was 83.5%, PPVHD was 92.1%, NPV-HD was 45%, sensitivity was 0.88, and specificity was 0.56. With M2, the overall accuracy for HD decreased to 82.8%, PPV-HD was 91.7%, NPV-HD was 43.1%, sensitivity was 0.87, specificity was 0.53, and mean AUROC was 0.87±0.03. With M3, overall accuracy for HD increased to 90.3%, PPV-HD was 95.2%, NPV-HD was 68.6%, sensitivity was 0.93, specificity was 0.76, and AUROC was 0.91±0.02. The use of basic EHR data combined with ML can exceed the accuracy of the RAPT. Applying big data on an individual level for this purpose may allow for safer and more appropriate discharge planning. [Orthopedics. 2022;45(4):e211-e215.].