Pre-Operative Patient Profile in Total Hip and Knee Arthroplasty Predictive of Increased Medicare Payments in Bundled Payment Model Beau Kildow, MD, Gerald Aggrey MD, Brian Dial MD, Vasili Karas MD,William Jiranek MD, Michael Bolognesi MD Department of Orthopaedics Duke University Medical Center December 9, 2017
Disclosures • No disclosures related to this study • I personally have no disclosures • Disclosures for Co-Authors: – Depuy (Royalties) – Biomet-Zimmer (Royalties) – Total Joint Orthopaedics (Consultant)
Introduction • 1 Million arthroplasties yearly, 15B industry • Est 200% (hips) and 600% (knees) ⬆ by 2030 • TJA is the highest volume of inpatient surgery for Medicare beneficiaries. – 90% of Adult Reconstruction practices are >50% Medicare – Only 10% restrict or cap Medicare – 39% of AAHKS members participating in a bundled payment model 1. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the Economic Downturn on Total Joint Replacement Demand in the United States. J Bone Jt Surg Am 2014;96:624 2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780
The Rules are Evolving • Consequence of – Increased financial burden on Regional Historical Payment Amounts Used to Calculate Target Prices CMS – Regional variability in average Table1. Episodes initiating between 1/1/2017 and 9/30/2017 price REGION 469 470 – Unaligned financial incentives and (1) New England $39,709.98 $22,904.94 outcomes (2) Middle Atlantic $41,403.62 $23,881.84 (3) East North Central $38,612.99 $22,272.19 (4) West North Central $36,136.37 $20,843.66 • Bundled Payment Model (5) South Atlantic $38,649.51 $22,293.25 (6) East South Central $38,544.50 $22,232.68 – Hospitals and physicians assume (7) West South Central $40,429.77 $23,320.12 greater financial responsibility (8) Mountain $36,371.47 $20,979.27 (9) Pacific $36,218.38 $20,890.96 – Increased scrutiny in outcomes Average $38,452.95 $22,179.88 and patient selection https://innovation.cms.gov/initiatives/cjr
Patients of All Shapes and Sizes… Increased interest in patient selection for arthroplasty procedures and also defining costs related to patient comorbidities and preoperative patient profile.
Administrative vs Institutional Data • Limited Data on Cost as it related to patient comorbidities – Population based “Big Data” studies – Accuracy of coding data to estimate medical profile has been called into question
Purpose • Identify pre-operative comorbidities that result in an increased financial burden within a single institution • Predict the specific increase in expenditure as a result of these comorbidities within a patient cohort composed of Medicare beneficiaries that would qualify for inclusion in CJR. – Secondarily, to identify whether there is a correlation between the number of comorbidities patients carry and their total Medicare payments across the bundled episode of 90 days.
Materials Medicare patients who • Perioperative Patient Profiles-Chart Review underwent primary total hip or total knee – Demographic data arthroplasty in 2013- – Age, gender, BMI, laboratory values 2014 at Duke – Detailed Comorbidity Profile • Reimbursement Data-Directly from CMS – Grand total cost to CMS of patient across proposed bundled Omit readmissions and period excluding costs of identified diagnoses/readmissions payments for excluded services within the from CJR guidelines episode of care – Break downs • Inpatient, outpatient, professional fees, readmissions, SNF, home health, DME
Results • Study Population-694 patients from 2013 to 2014 Table 3. Demographic results of 694 patient cohort Current Mean Standard Deviation smoker Age 69.93 9.23 6% THA Never 40% Length of Stay 3.26 1.4 smoker 48% Former Gender 60% Female 40% Male TKA smoker 60% BMI 29.89 5.8 46% Charlson-Deyo Score 1.75 2.36 Preoperative Hematocrit 0.41 0.04 Preoperative Glucose 93.1 24.11
Results • Study Population: Coincident with Medicare population in the southeast region
Results Cost Breakdown per Episode Mean Cost per Episode: $23,046.40
Results • Specific comorbidities have a statistically significant resultant increase in Medicare payments (p<0.05) • Range $2,182 to $9,845 increase from baseline
Results MEDICARE PAYMENT INCREASE WITH COMORBIDITY 32,000 30,000 TOTAL MEDICARE PAYMENTS 28,000 26,000 24,000 22,000 20,000 0 1 2 3 4 5 6 7 8 9 10 NUMBER OF COMORBIDITIES • Medicare payments increased with increasing number of comorbidities (p<0.001) • Mean of $671.04 increased cost per comorbidity
Conclusions • First study to examine payments inclusive of index admission, professional fees, total 90 day costs and CJR identified exclusions • Specific, identifiable comorbidities increase Medicare payments in a 694 institutional patient cohort for primary total hip and knee arthroplasty • Increased number of comorbidities = Increased Medicare payments MEDICARE PAYMENT INCREASE WITH COMORBIDITY 32,000 TOTAL MEDICARE PAYMENTS 30,000 28,000 26,000 24,000 22,000 20,000 0 2 4 6 8 10 NUMBER OF COMORBIDITIES
Discussion • Value based Care Need for predictive models of cost based on patient profile • Identify modifiable comorbidities and chronic disease Modify them! Preop! • Medical Haves and Have Nots and Cherry Picking Role of further stratification
Moving forward. Climbing higher.
Current Practice at Duke CJR – Risk Stratification Guidelines for Elective Primary Total Knee, Hip, Ankle Replacements- Duke Health System Consensus or Evidence Based- 2016 1. BMI 40 or greater 2. Active smoker- must begin cessation program 3. HgA1C > 7.5% (>8%?) 4. Albumin of 3 or less (?3.4 or less) 5. Anemia - Hgb less than 11 6. Thrombocytopenia- platelets less than 50k 7. ESRD on dialysis 8. Coronary stenting with or without AMI within the past 6 months (?12 months) 9. Stroke or TIA within previous 6 months 10. Any active infections; any open wounds on the lower extremity posted for surgery 11. Other significant issues- e.g. uncontrolled hypo-hyper thyroidism/ hyperparathyroidism, ASA 4, COPD on oxygen, etc. 12. Chronic high dose narcotic use (addiction) Patients that do not meet these criteria may occasionally receive surgery if reviewed and approved by a faculty panel at Preoperative Conference.
Comprehensive Care for Joint Replacement Model (CJR by CMS) • Mandated Bundle Payment model- Medicare Part A & B- Section 1115A of the Social Security Act- started April 1, 2016- Lower Extremity Joint Replacements, participant hospitals held financially accountable for quality and cost of 90 day episodes for MS-DRG’s 469 (with MCC) and 470 (without MCC) • 67 Metropolitan Statistical Areas (791 hospitals) for 5 years; CMS sets pricing targets for both DRG’s with or without hip fractures (primary total hips, total knees, and total ankles); standard fee for service payments with retrospective reconciliation (about 12-18 months later- maybe) • Quality metrics- Hospital level risk- standardized complications (NQF#1550)- 50%, HCAHPS (NQF#0166)-40%, patient reported outcomes (PROMIS- Global Health+Pain, HOOS, KOOS, Ankle)-10%; point system by percentile rank; rated excellent, good, acceptable- affects reconciliation payment or discounts repayment • Potential gains/losses calculated by CMS- +5%- Year 1; +/-5% Year 2; +/- 10% Year 3, +/- 20% Year 4 and 5 (Hospital at risk- stop loss of 50% any episode; and pay for cumulative savings- also stop gain in any given year) • Waivers- 3 night hospital stay for SNF (year 2); payments for home visits or telehealth; gain sharing with collaborators (including surgeons) • Patients maintain freedom of choice; required CMS bundle disclosure forms
DRG 470…
DRG 469…
Comorbidities Evaluated Table 1. Preoperative Comorbidities included in the development of a detailed patient profile Preoperative Comorbidities Congestive Heart Failure HIV/AIDS Arrhythmia Lymphoma Valvular Disease Metastatic Cancer Circulatory Disease Non-Metastatic Tumor Peripheral Vascular Disease Rheumatoid Arthritis Hypertension Coagulopathy Paralysis Obesity Neurologic Disease Recent Weight Loss Chronic Pulmonary Disease Electrolyte Disorder Diabetes Mellitus Anemia Hypothyroidism Alcoholism Renal Failure Drug use Liver Disease Psychoses Peptic Ulcer Disease Depression Demographic Data Gender Surgery Smoking Status Age BMI
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