The Impact of Mandatory Bundled Payment on Prehabilitation Delivery for Lower Extremity Joint Replacement.

Abstract

To determine the effect of bundled payment for inpatient lower extremity joint replacement (LEJR) on preoperative rehabilitation ("prehabilitation") delivery. Difference-in-differences analysis comparing the proportion of hospitals delivering LEJR prehabilitation before and after implementation of the Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model in CJR Treatment versus Control areas. Inpatient facilities in CJR treatment and control areas conducting elective LEJR surgery for Medicare beneficiaries in the United States PARTICIPANTS: Using claims from a 20% sample of Medicare beneficiaries, we identified 62,217 Medicare beneficiaries who received an incident elective inpatient LEJR between July 1, 2015 and December 31, 2017 and were continuously enrolled in Medicare fee-for-service 6 months preceding surgery at 945 hospitals (385 CJR Treatment, 560 Control) INTERVENTION: CJR mandatory bundled payment model for LEJR MAIN OUTCOME MEASURES: Change in proportion of hospitals delivering prehabilitation, defined as at least two patients receiving qualifying preoperative rehabilitation services in a given quarter RESULTS: The average quarterly proportion of hospitals delivering LEJR prehabilitation increased in both CJR treatment (from 8.94% to 14.62%) and control areas (from 10.19% to 12.72%). In adjusted difference-in-difference analyses, we observed a 3.46 (95% CI, 0.26 to 6.65) percentage point greater increase in the average proportion of hospitals delivering prehabilitation in CJR treatment areas relative to control areas after implementation. Implementing mandatory bundled payment promoted an increase in LEJR prehabilitation delivery. Future research is needed to explore the role prehabilitation may play in supporting quality outcomes while reducing episodic spending.