With health care costs in the United States rising at an exponential rate, providers, payers, and policymakers have all sought to develop alternative payment models to seek value in care. For procedures such as total knee arthroplasty (TKA), which accounts for Medicare’s largest inpatient expenditure, the Centers for Medicare and Medicaid Services (CMS) and private insurers have introduced bundled payment programs aimed at reducing cost and improving the quality of patient care. Although traditionally, TKA has been reimbursed by Medicare through a fee-for-service model rewarding quantity of services provided versus quality of service, the Bundled Payments for Care Improvement Initiative (BPCI) and the Comprehensive Care for Joint Replacement Model (CJR) seek to align incentives among providers and health care systems by providing a single payment for all services rendered during an episode of care for TKA. Although early published data from these programs suggests substantial cost savings to CMS without an increase in complications, concerns exist regarding access to care for patients who may utilize more resources in an episode of care. Without appropriate risk adjustment, providers are disincentivize to perform TKA on patients at risk for complications and readmissions. Alternative payment models have reduced costs and improved patient outcomes by incentivizing providers to optimize modifiable risk factors before elective TKA, including glycemic control, smoking, body mass index, and malnutrition. Several studies, however, have shown that nonmodifiable risk factors including advanced age, lower socioeconomic status, and several medical and orthopaedic comorbidities are costlier to the health care system following TKA. These patients may face difficulty obtaining quality arthroplasty care with the expansion of bundled payment programs. In order to protect access to care, alternative payment models should not penalize surgeons and hospitals for caring for complex patients and instead provide appropriate, fair, risk-adjusted payments.
*Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA
†Rush University Medical Center, Chicago, IL
This project was supported by an unrestricted grant from KCI, an Acelity company.
The authors declare that they have nothing to disclose.
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