For the first time, a new report analyzes Medicare’s mandatory bundling program known as Comprehensive Care for Joint Replacement, or CJR, from the state perspective.

As the healthcare system shifts away from traditional fee-for-service payment models, bundled payment initiatives have become a popular tool to attempt to decrease cost and increase quality of care. Bundled payments are initiatives designed to pay the healthcare provider for an entire episode of care rather than individual services.

NJHA’s Center for Health Analytics, Research & Transformation (CHART) analyzed New Jersey data from 2015 to 2018 to identify whether the program is achieving the goal of reduced cost and better outcomes for patients who were treated at CJR-mandated hospitals in comparison to those who were treated at hospitals participating in another bundled payment initiative or not participating in any bundled payment program at all.

The analysis shows that, while there are noticeable changes in discharge status trends correlated to the types of bundled payment programs, more research is needed to determine any links between utilization trends and overall quality and good patient outcomes.

“We know CJR has had an effect on healthcare costs and utilization across the country, but that’s only part of the story,” said NJHA President and CEO Cathy Bennett. “CHART’s study turns the lens toward how Medicare beneficiaries fare after complete knee or hip replacements as an attempt to fill in the gaps in underreported patient outcomes as well as to point out shortcomings in the information providers have. We can’t improve patients’ health if we don’t know the human results of these initiatives.”

For New Jersey’s senior population, the question of quality is increasingly important as the number of 65-and-older residents continues to grow. Pressures on the healthcare system to continually monitor quality of life and emphasizing seniors staying in the community increase with greater life expectancies. For seniors recovering from joint replacement surgery at home or in outpatient settings, knowing that their functional recovery is optimal is critical to helping them be independent longer.

In Medicare's Comprehensive Joint Replacement Program: Are Medicare Beneficiaries Benefitting?, the CHART team compared data on the discharge status of 102,249 patients from three different cohorts of hospitals: hospitals participating in the CJR bundle (67,516 patients); hospitals participating in a different bundle called the Bundled Payment for Care Improvement “Classic” program, or BPCI (18,277); and hospitals that participated in neither of these initiatives (16,456).

The analysis looked at patients’ length of stay, the types of care settings patients were discharged to, readmission rates and whether racial disparities exist among Medicare beneficiaries undergoing joint replacement at hospitals participating in the CJR bundle.

The findings show that since CJR was mandated for 38 New Jersey hospitals in 2016:

• Length of stay for joint replacement patients declined in CJR, BPCI and non-bundle hospitals, from 3.2 days to 2.6 days, 2 days to 1.7 days, and 2.9 days to 2.4 days, respectively. Reduced length of stay is a desired result indicating improved efficiency of care. Discharge to inpatient rehabilitation facilities decreased in all three settings, as well. Both of these trends align with national results.
• CJR hospitals saw large changes in discharges to skilled nursing facilities, from 45 percent of patients to 26 percent, and to home with home health assistance, from 26 percent to 52 percent.
• BPCI hospitals had a large uptick in discharge to home with self care, from 29 percent to 60 percent of patients, and a large decrease of discharge to home health assistance, from 50 percent to 23 percent.
• Hospitals not participating in a bundling initiative saw the greatest change in the increase of patients discharged to home with self care, from 28 percent to 46 percent.
• Among counties with CJR hospitals, blacks and Asians were less likely to undergo joint replacement procedures compared to their relative percentage of the population. Blacks make up 8.1 percent of patients compared to 12 percent of the counties’ population, while Asians make up 3.3 percent of patients compared to 10 percent of the population.

While these findings demonstrate that the CJR bundle has had an effect on reducing length of stay in New Jersey, they also highlight the need for additional investigation of whether complex patients who would previously have gone to an inpatient rehabilitation facility are receiving the services they require at a skilled nursing facility or in outpatient care, as well as other indicators of quality patient outcomes.

The report lists several more recommendations to advance the dialogue; they include:

• Measuring success of CJR, or any bundling initiative, should not be based solely on changes in utilization patterns and resources expended. Functional and emotional status of patients during and after the episode of care are important markers of impact.
• Future evaluation of CJR should include measures of social determinants of health such as food insecurity, adequacy of housing, neighborhood safety, financial security, social isolation, accessibility of transportation, etc., as these factors could have an adverse impact on the ability of patients to follow through on rehabilitation programs, follow-up appointments and medication adherence.
• Further investigation into racial disparities in joint replacement procedures is an important step in understanding potential barriers to equitable healthcare, including access to care, cultural biases and potential comorbidities present in these populations.
• Understanding utilization of other Medicare-funded services after the end of the episode such as physician visits, outpatient rehabilitation services, skilled nursing or surgical procedures related to the original joint replacement surgery could also be an important way to evaluate bundled programs.

Visit the CHART website at www.njha.com/CHART to download a copy of the full report and access interactive graphics for additional detail.