Total Knee Arthroplasty Outcomes in Patients with Medicare, Medicare Advantage, and Commercial Insurance

Abstract

As more commercial insurance companies adopt a bundled reimbursement model, similar to the Comprehensive Care for Joint Replacement (CJR) algorithm for Medicare beneficiaries, accurate risk adjustment of patient-reported outcomes (PROs) is critical to ensure success. With this movement toward bundled reimbursement, it is unknown if a formula adjusting for similar risks in the Medicare population could be applied to PROs in commercially insured and Medicare Advantage populations undergoing total knee arthroplasty (TKA). This study was performed to compare PROs after TKA in these insurance groups after adjusting for proposed risks. Demographics and clinical data were abstracted from medical records of 302 patients who underwent TKA performed by a single surgeon at a university-based orthopaedic practice during 2013 to 2017. Differences in PROs between commercially insured, Medicare Advantage, and Medicare patients during the 6 months following surgery were evaluated while controlling for demographics, clinical data, and baseline PRO scores. Medicare and Medicare Advantage patients were older (p < 0.001) and had more comorbidities (p = 0.001) than commercial patients. During the first 3 months following TKA, patients in all three groups experienced similar rates of recovery. At 6 months after surgery, outcomes began to diverge by insurance group. Medicare patients reported significantly less ability to perform activities of daily living (78.6 vs. 63.2; p = 0.001), worse physical function (39.6 vs. 44.9; p = 0.003), and more pain interference (57.9 vs. 52.4; p = 0.018) at day 180 than commercially insured patients. There were no statistically significant differences between Medicare Advantage patients and either commercially insured or Medicare patients. Therefore, commercial insurance companies that intend to apply a risk-adjusted equation similar to the CJR algorithm to commercial populations should be cautioned since the postoperative outcomes in this investigation differed after adjusting for the same risk factors that have been proposed for inclusion in the CJR algorithm. Nonetheless, further studies should be performed to ensure that companies participating in bundled reimbursement models have a positive influence on comprehensive health care for patients and providers. This is a level III, retrospective prognostic study

Keywords

arthroplasty - knee - outcomes - insurance

• References

• 1 Cutler DM, Ghosh K. The potential for cost savings through bundled episode payments. N Engl J Med 2012; 366 (12) 1075-1077
• 2 Hassan M, Tuckman HP, Patrick RH, Kountz DS, Kohn JL. Hospital length of stay and probability of acquiring infection. Int J Pharm Health Mark 2010; 4: 324-338
• 3 Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/cjr . Accessed August 9, 2017
• 4 Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule. Fed Regist 2015; 80 (226) 73273-73554
• 5 Clement RC, Derman PB, Kheir MM. , et al. Risk adjustment for Medicare total knee arthroplasty bundled payments. Orthopedics 2016; 39 (05) e911-e916
• 6 BlueCross and BlueShield of North Carolina. BSBSNC and OrthoCarolina Team Up to Reduce Cost and Improve Quality of Knee Replacement Surgeries. http://mediacenter.bcbsnc.com/news/bcbsnc-and-orthocarolina-team-up-to-reduce-cost-and-improve-quality-of-knee-replacement-surgeries . Accessed June 10, 2018
• 7 Dean PP. Bundled Payment Models – Comprehensive Care for Joint Replacement. Denver, CO: Holland & Hart; 2016
• 8 Fry DE, Pine M, Nedza SM, Locke DG, Reband AM, Pine G. Risk-adjusted hospital outcomes in medicare total joint replacement surgical procedures. J Bone Joint Surg Am 2017; 99 (01) 10-18
• 9 OrthoCarolina Research Institute. Going to the Doctor: Why Are There So Many Forms? https://orthocarolinaresearch.org/newsroom/going-to-the-doctor-why-are-there-so-many-forms/ . Accessed June 10, 2018
• 10 Humbyrd CJ. The ethics of bundled payments in total joint replacement: “cherry picking” and “lemon dropping”. J Clin Ethics 2018; 29 (01) 62-68
• 11 Kamath AF, Courtney PM, Bozic KJ, Mehta S, Parsley BS, Froimson MI. Bundled payment in total joint care: survey of AAHKS membership attitudes and experience with alternative payment models. J Arthroplasty 2015; 30 (12) 2045-2056
• 12 Rosenthal BD, Hulst JB, Moric M, Levine BR, Sporer SM. The effect of payer type on clinical outcomes in total knee arthroplasty. J Arthroplasty 2014; 29 (02) 295-298
• 13 American Physical Therapy Association. CJR-FAQ: comprehensive care joint replacement model frequently asked questions. APTA 2016 ;1–58
• 14 Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; 28 (02) 88-96
• 15 Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas 2010; 11 (03) 304-314
• 16 Centers for Medicare and Medicaid Services. Things to know about Medicare Advantage Plans. https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/things-to-know-about-medicare-advantage-plans . Accessed July 2, 2018
• 17 Medicare Rights Center. Differences between Original Medicare and Medicare Advantage Plans. http://www.medicarerights.org/fliers/Medicare-Advantage/Differences-Between-OM-and-MA.pdf?nrd=1 . Accessed July 2, 2018
• 18 United States Government Accountability Office. Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy. August 2015. Available at: https://www.gao.gov/assets/680/672236.pdf . Accessed July 2, 2018
• 19 Charlson M, Wells MT, Ullman R, King F, Shmukler C. The Charlson comorbidity index can be used prospectively to identify patients who will incur high future costs. PLoS One 2014; 9 (12) e112479
• 20 Keyes BE, Liu S, Asare A. , et al. Impaired epidermal to dendritic T cell signaling slows wound repair in aged skin. Cell 2016; 167 (05) 1323-1338.e14
• 21 Maempel JF, Riddoch F, Calleja N, Brenkel IJ. Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients. Acta Orthop 2015; 86 (04) 451-456
• 22 Lovald ST, Ong KL, Malkani AL. , et al. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthroplasty 2014; 29 (03) 510-515