title: Cost of Joint Replacement Using Bundled Payment Models.
abstract: Medicare launched the mandatory Comprehensive Care for Joint Replacement bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles.
  
  
  
  To analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC.
  
  
  
  This observational study followed 3942 total patients with lower extremity joint replacement at Baptist Health System (BHS), which participated in ACE and BPCI.
  
  
  
  Lower extremity joint replacement surgery under bundled payment at BHS.
  
  
  
  Average Medicare payments per episode, readmissions, emergency department visits, prolonged length of stay, and hospital savings from changes in internal hospital costs and PAC spending.
  
  
  
  Overall, 3942 patients (mean [SD] age, 72.4 [8.4] years) from BHS were observed. Between July 2008 and June 2015, average Medicare episode expenditures declined 20.8%, from $26 785 to $21 208 (P < .001) for 3738 episodes of joint replacement without complications. It declined 13.8% from $38 537 to $33 216 (P = .61) for 204 episodes of joint replacement with complications. Readmissions and emergency department visits declined 1.4% (P = .14) and 0.9% (P = .98), respectively, while episodes with prolonged length of stay decreased 67.0% (P < .001). Patient illness severity remained stable. By 2015, 51.2% of overall hospital savings had come from internal cost reductions and 48.8% from PAC spending reductions. Reductions in implant costs, down on average $1920.68 (29%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined $2443.12 (27%) per case, largely from reductions in inpatient rehabilitation and skilled nursing facility spending but only when bundles included financial responsibility for PAC.
  
  
  
  During a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, The Wharton School, University of Pennsylvania, Philadelphia3Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania.
authors.forename: Amol S
authors.initials: AS
authors.lastname: Navathe
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Troxel
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, The Wharton School, University of Pennsylvania, Philadelphia.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Liao
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Nan
authors.initials: N
authors.lastname: Nan
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Jingsan
authors.initials: J
authors.lastname: Zhu
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Wenjun
authors.initials: W
authors.lastname: Zhong
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, The Wharton School, University of Pennsylvania, Philadelphia.
authors.forename: Ezekiel J
authors.initials: EJ
authors.lastname: Emanuel
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000191:economics*; D019645:Arthroplasty, Replacement, Knee / Q000191:economics*; D017046:Cost Savings; D017050:Episode of Care; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D006278:Medicare / Q000191:economics; D064872:Patient Care Bundles; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications; D011787:Quality of Health Care; D014481:United States