The Race to the Bottom: A High-Volume Hospital Experience With Comprehensive Care for Joint Replacement

Area of Science:

• Orthopedic Surgery
• Healthcare Management
• Value-Based Care

Background:

• The Comprehensive Care for Joint Replacement (CCJR) initiative aimed to enhance quality and reduce costs for total joint arthroplasty (TJA) episodes.
• This value-based program introduced financial risks and incentives for healthcare providers.
• Understanding the impact of CCJR on clinical and financial outcomes is crucial.

Purpose of the Study:

• To evaluate the outcomes of the CCJR program on TJA episodes.
• To assess the program's effect on quality metrics, cost, and financial reconciliation.
• To determine the long-term sustainability of CCJR under declining reimbursement.

Main Methods:

• A multidisciplinary CCJR team was established, including care coordinators, nurse navigators, physicians, and financial experts.
• Regular meetings and subgroup analyses focused on patient optimization, readmissions, skilled nursing facility (SNF) utilization, and patient education.
• Statistical analyses, including Chi-square tests, were used to evaluate changes in key performance indicators (P < 0.05).

Main Results:

• Skilled nursing facility utilization decreased significantly from 28.8% to 6.7% (P < 0.00001).
• Readmission rates dropped from 7.4% to 4.1% (P < 0.001).
• While initial average reconciliation per case was positive ($2,798.54), it became negative (-$163.75) by the final year, resulting in a net loss of $255,621.

Conclusions:

• The CCJR program successfully improved quality metrics during TJA episodes despite decreasing reimbursement.
• Sustained quality improvements necessitated increased staffing, impacting financial viability.
• The declining reimbursement structure within CCJR is not financially sustainable in the long term.