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

Comprehensive Care for Joint Replacement (CCJR) is a value-based system designed to increase quality and decrease cost for the total joint arthroplasty (TJA) episode of care. The creation of this program created financial incentives and risk for both hospitals and physicians during the TJA episode of care. Herein, we describe our results during the program.

We created a CCJR team consisting of care coordinators, nurse navigators, physicians, and a financial team. Quarterly meetings were instituted to monitor for changes and review outliers. Multiple subgroups were created to work on patient optimization, readmission, skilled nursing facility usage, and patient education. Nurse navigators monitored for any potential patient complications to prevent readmissions. Data were recorded, and statistical analyses were performed using Chi-square tests with significance set at P < 0.05.

Our target price for diagnosis-related groups 470 has decreased from $29,009 to $27,503, and our episode cost increased from $25,815 to $27,688. During the period from 2016 to 2023, we achieved a substantial decrease in skilled nursing facility utilization (28.8 to 6.7%, P < 0.00001) and readmission rate (7.4 to 4.1%, P < 0.001). The average reconciliation per case decreased from $2,798.54 to -$163.75. The net payment reconciliation amount went from a high of $5,389,983 to a final year loss of $255,621.

During the CCJR period, we markedly increased quality during the TJA episode with decreasing reimbursement. We maintained positive reconciliations per case until the final year, in which reconciliation turned negative. Increased full-time and voluntary staff were required to increase quality metrics despite declining reimbursement. The continued decrease in reimbursement is not sustainable over time.

III retrospective data analysis.