Bundled payment impacts uptake of prescribed home health care

To determine whether the CMS Comprehensive Care for Joint Replacement (CJR) Model, which incentivizes coordinated and efficient care, increased home health care (HHC) uptake among patients referred to HHC after major joint replacement surgery.

Cohort study using a difference-in-differences design comparing hospitals in 75 metropolitan statistical areas randomized into CJR by CMS with non-CJR hospitals in 119 areas as controls.

The primary outcome was the case mix-adjusted, hospital-level HHC uptake rate, which is the rate of patients referred to HHC at hospital discharge receiving an HHC visit within 14 days. Secondary outcomes included HHC uptake rate by race/ethnicity and the quality of HHC agencies used among referrals, which was measured by agency-level improvement in ambulation, unplanned hospitalizations, emergency department visits, time to the first home health visit, and distinct number of agencies.

After the launch of CJR, HHC uptake decreased nationally but there was a 3.73-percentage point (4.5%) lower decrease in CJR hospitals; this was driven by White patients (3.54-percentage point differential; P = .026). A marginally statistically significant (P = .054) 5.05-percentage point differential increase for Black patients was observed due to a slight increase in the treatment group and a large decrease in the control group. There was no statistically significant change for Hispanic or Asian American/Pacific Islander populations. No statistically significant increases were observed in the quality of HHC used.

CJR mitigated a trend of decreased HHC uptake, but more work is needed to improve uptake for larger portions of the patient population. Our results suggest that addressing care coordination incentives via CJR may mitigate some racial disparities.