The Impact of Medicare Bundled Payments

NCT03407885 | Completed

• 1 other identifier: JPAL-0740
• Study Type: interventional
• Target: 196
• Locations: 0 countries
• Sites: N/A

Brief Summary

Bundled payments (BP) are a key part of Medicare's shift away from the traditional fee-for-service (FFS) payment model. The investigators propose to study a nationwide randomized-controlled trial (RCT) of bundled payments for knee and hip replacements that was designed and implemented by CMS and launched in April 2016. Randomization was conducted at the Metropolitan Statistical Area (MSA) level with 67 MSAs and about 800 hospitals assigned to the treatment group. The investigators will examine the impact of bundled payments on Medicare spending, utilization, and quality. Study findings should be directly relevant for the design of payments for knee and hip replacements, two common and expensive medical procedures. Average impacts, as well as variation in impact across types of providers and markets may also shed light on economic mechanisms, which should be relevant for bundled payment initiatives under consideration for other medical services.

Conditions

Arthroplasty, Replacement

Outcome Measures

Primary Outcomes (1)

• Share of LEJR admissions discharged to institutional Post-Acute Care (PAC)

  Share of lower extremity joint replacement (LEJR) index admissions discharged to institutional post-acute care facilities (i.e. skilled nursing facilities (SNF), long term care hospitals (LTCH) or inpatient rehabilitation facilities (IRF)). LEJR index admissions are eligible admissions at acute care hospitals (ACH) that result in a discharge in either DRG 469 or 470.

  At hospital discharge up to 3 days

Secondary Outcomes (6)

• Share of LEJR admissions discharged to any Post Acute Care (PAC)

  At hospital discharge up to 3 days

• Number of days in Institutional PAC during episode

  Begins with index admission and ends 90 days post-discharge from index admission

• Total covered Medicare payments during episode

  Begins with index admission and ends 90 days post-discharge from index admission

• Total covered Medicare payments for Institutional PAC during episode

  Begins with index admission and ends 90 days post-discharge from index admission

• Total covered Medicare payments for any PAC during episode

  Begins with index admission and ends 90 days post-discharge from index admission

Other Outcomes (11)

• Any THA/TKA complication

  Begins with index admission and ends 90 days post-discharge from index admission

• Number of THA/TKA complications

  Begins with index admission and ends 90 days post-discharge from index admission

• Share of LEJR admissions with an ER visit within 90-days of discharge from index admission

  Begins with index admission and ends 90 days post-discharge from index admission

Study Arms (2)

Experimental

EXPERIMENTAL

Bundled payments for knee and hip replacement

Other: Bundled payments for knee and hip replacement

Control

NO INTERVENTION

No intervention

Interventions

Bundled payments for knee and hip replacement OTHER

The bundled payment model holds acute care hospitals (ACHs) financially responsible for the spending and quality of an entire episode of care for two types of hospital admissions: MS-DRG 469 and 470. An episode begins with an ACH stay that results in a discharge in one of the two DRGs, and ends 90 days after discharge. Before each performance year begins, hospitals receive target prices from CMS, determined by historical hospital and regional episode expenditures. Hospitals are eligible for reconciliation payment from CMS if they spend less than the target prices for an episode, provided that they met an "acceptable" quality standard. Conversely, they are responsible for paying the difference if they spend more than the target prices.

Experimental

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

• Acute care hospital paid under the inpatient prospective payment system (IPPS)
• Hospital admission for major joint replacement or reattachment of lower extremity with and without major complications or comorbidities (MS-DRG 469 and 470)

You may not qualify if:

• MSAs with low volume of LEJR
• MSAs with high take-up of BPCI
• MSAs with large share of LEJR in Maryland hospitals
• Hospitals participating in certain models of BPCI.
• Patient not covered by both Medicare Parts A and B
• Patient eligibility for Medicare is due to end stage renal disease (ESRD)
• Patient is in a managed care plan
• Patient is in a United Mine Workers of America Plan
• Medicare is not the primary payer for the patient
• Patient dies during the episode
• Patient is re-admitted to an ACH for one of the two CJR DRGs during the episode
• Patient initiates an LEJR episode under BPCI during the episode
• Payments and services that occur in the episode that are excluded are:
• hemophilia clotting factors
• new technology add-on payments

Sponsors & Collaborators

• Amy Finkelstein: lead
• Harvard University: collaborator
• University of Chicago: collaborator
• Dartmouth College: collaborator

Related Publications (3)

• Finkelstein A, Ji Y, Mahoney N, Skinner J. Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care: Interim Analysis of the First Year of a 5-Year Randomized Trial. JAMA. 2018 Sep 4;320(9):892-900. doi: 10.1001/jama.2018.12346.

  PMID: 30193277 RESULT

• Einav L, Finkelstein A, Ji Y, Mahoney N. Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform. Proc Natl Acad Sci U S A. 2020 Aug 11;117(32):18939-18947. doi: 10.1073/pnas.2004759117. Epub 2020 Jul 27.

  PMID: 32719129 RESULT

• Einav L, Finkelstein A, Ji Y, Mahoney N. VOLUNTARY REGULATION: EVIDENCE FROM MEDICARE PAYMENT REFORM. Q J Econ. 2022 Feb;137(1):565-618. doi: 10.1093/qje/qjab035. Epub 2021 Sep 20.

  PMID: 35233120 RESULT

MeSH Terms

Interventions

Arthroplasty, Replacement, Hip

Intervention Hierarchy (Ancestors)

Arthroplasty, Replacement; Arthroplasty; Orthopedic Procedures; Surgical Procedures, Operative; Plastic Surgery Procedures; Prosthesis Implantation

Study Officials

• Amy N Finkelstein, PhD

  Massachusetts Institute of Technology

  PRINCIPAL INVESTIGATOR

• Yunan Ji

  Harvard University

  PRINCIPAL INVESTIGATOR

• Neale Mahoney, PhD

  University of Chicago

  PRINCIPAL INVESTIGATOR

• Jon Skinner, PhD

  Dartmouth College

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR INVESTIGATOR
• PI Title: Scientific Director, J-PAL North America

Study Record Dates

• First Submitted: October 13, 2017
• First Posted: January 23, 2018
• Study Start: April 1, 2016
• Primary Completion: December 1, 2017
• Study Completion: February 1, 2022
• Last Updated: March 3, 2022

Record last verified: 2022-02

Data Sharing

• IPD Sharing: Will not share