Abstract The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study ...is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospital’s administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.
Abstract Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint ...arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.
Abstract Reducing the cost of total joint implants can significantly reduce the cost of an episode of care without affecting the quality. In 2011 we began a program to decrease and standardize the ...pricing of total joint implants. In the first year of the intervention we preformed 1,090 and 1,022 unilateral total knee and total hip arthroplasties respectively. Based on our volume and pricing data, our institution saved over $2 million during the first year of this intervention. It is clear that our initiative to negotiate lower implant cost with our vendors has lead to a significant reduction in the cost of joint arthroplasties and a reduction in the variability in costs between physicians.
Abstract There is currently wide variation in the use and cost of post acute care following total joint arthroplasty. Additionally the optimum setting to which patients should be discharged after ...surgery is controversial. Discharge patterns following joint replacement vary widely between physicians at our institution, however, only weak correlations were found between the cost of discharge and length of stay or readmission rates. The inter-physician variance in discharge cost did not correlate to a difference in quality, as measured by length of stay and readmission rates, but does imply there is significant opportunity to modify physician discharge practices without impacting patient outcomes and the quality of care.
Abstract In order to control the unsustainable rise in healthcare costs the Federal Government is experimenting with the bundled payment model for total joint arthroplasty (TJA). In this risk sharing ...model, providers are given one payment, which covers the costs of the TJA, as well as any additional medical costs related to the procedure for up to 90 days. The amount and severity of comorbid conditions strongly influence readmission rates and costs of readmissions in TJA patients. We identified 2026 TJA patients from our database with APR-DRG SOI data for use in this study. Both the costs of readmission and the readmission rate tended to increase as severity of illness increased. The readmission burden also increased as SOI increased, but increased most markedly in the extreme SOI patients.
Abstract Preoperative screening and decolonization of methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA, respectively) are advocated to reduce surgical site ...infections. We determined the rate and duration of decolonization in patients undergoing elective orthopedic surgery. Patients undergoing elective orthopedic surgery were seen in our preoperative testing program (PAT) and had their anterior nares cultured for MRSA and MSSA. All patients were treated with intranasal mupirocin and a topical chlorhexidine solution. A cohort of patients returned to PAT before a subsequent elective procedure and were recultured. All culture results and time between PAT visits were recorded, and the rates of successful initial and persistent decolonization were determined. Six hundred ten patients visited PAT 1290 times. Overall, 94 (70.1%) of 134 patients with initially MRSA- or MSSA-positive cultures remained decolonized at a mean time of 156 days (SD=140), whereas 40 patients (29.9%) were not decolonized by the time of repeat testing at a mean time of 213 days (SD=187). At repeat testing, there were 2 newly MRSA-positive and 35 newly MSSA-positive patients. Staphylococcus aureus decolonization with intranasal mupirocin and topical chlorhexidine was effective but not persistent in a significant proportion of patients. A small number of previously uncolonized patients became colonized. Staphylococcus aureus screening and decolonization protocols must be repeated before any readmission, regardless of prior colonization status.
Abstract Introduction Hospital reimbursement for Medicare/Medicaid/self-pay patients has not kept pace with rising expenses, and even well run efficient organizations struggle to maintain a positive ...margin on these cases. Therefore, hospitals rely on commercially insured patients to remain economically viable. However, hospitals located in areas with a high Medicare/Medicaid/uninsured population cannot depend on a favorable payer mix for financial sustainability. Methods Using the SPARCS database, TJAs in New York from 2000-2012 were identified. Hospitals were divided into quartiles by volume, with quartile 1 representing the lowest volume hospitals. TJA cases were stratified by primary payer type and the percentage of each primary payer type was calculated and compared amongst quartiles. Results The highest number of hospitals performing TJAs was 207 in 2000, and the least number of hospitals was in 2012, with only 178 hospitals performing TJA. Despite the decrease in the number of hospitals, the total number of joint replacements increased from 33,036 in 2000, to 62,104 in 2012. Conclusions Our study demonstrates that higher volume hospitals tended to have, a more favorable payer mix (less Medicare/Medicaid/self-pay patients). This inequity widened over the 12 year study period. This trend has ethical implications for lower socioeconomic status patients as high volume centers tend to have superior outcomes compared to low volume centers. Additionally the lower volume-high Medicare/Medicaid/self-pay hospitals are more susceptible to CMS quality penalties making their economic viability even more tenuous potentially leading to access of care problems for these patients.
