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  • Separate Studies, Similar Conclusions: Bundling for Knee, Hip Replacement Seems to be Working

    Has all the bundling been worth it? Two new studies of bundled care models used by the Centers for Medicare and Medicaid Services (CMS) conclude that, at least for lower extremity joint replacement (LEJR), the answer is yes. Taken as a whole, the studies make the case that while the savings achieved through some bundled care models may not be dramatic, they do exist — and aren't associated with a drop in quality.

    The studies, published in Health Affairs, take different approaches to answering questions about the effectiveness of bundling programs mostly associated with CMS' voluntary Bundled Payments for Care Improvement (BPCI) initiative: one was a systematic review that analyzed existing research (abstract only available for free) on the programs, while the other focused on data from hospitals that did and did not participate in BCPI (abstract only available for free) over a three-year period. Their conclusions, however, had much in common.

    The bottom line, according to both studies, is that bundled care models for LEJR seem to be lowering overall costs without sacrificing quality.

    The systematic review revealed that most studies that evaluated spending recorded decreases in overall postacute care spending of between $591 and $1,960, while the hospital data researchers identified an average 1.6% decrease in episode spending for LEJR — about $377 per patient. At the same time, neither study uncovered evidence of reduced quality outcomes, with the hospital study finding variances between BPCI and non-BPCI care for LEJR of less than 2%. The systematic review found that, if anything, research indicates that bundled care tends to lead to lower rates of hospital readmission, a datapoint strongly associated with quality.

    The studies did have some differences. The hospital data researchers focused solely on LEJR data, which they describe as the most common procedure associated with BPCI, while the systematic review included a bundled care model for a range of procedures. In the end, authors of the systematic review found that bundled payment "has yet to demonstrate [benefits similar to those associated with LEJR bundling] for other clinical episodes," including spinal fusion, shoulder arthroplasty, and cardiac surgery. Another difference between the studies: The systematic review included data from CMS' Comprehensive Care Joint Replacement (CJR) model mandated for use in some 450 facilities across the country; the hospital data review excluded CJR facilities.

    [Editor's note: APTA offers multiple resources on bundling, including separate webpages devoted to BPCI Advanced participation and the CJR.]

    Each study offered its own takeaways. The systematic review emphasized the effectiveness of bundling for LEJR and suggested that CMS "scale up” its bundling programs in those areas, while cautioning that more work needs to be done on bundling programs for other procedures, especially those that tend to be associated with higher baseline patient complexity. The hospital data study, focused on LEJR only, found that most of the savings associated with bundling came from early adopters (which maintained their savings over time), and less so from facilities that joined later, which "may have been less able to influence episode spending." That study also acknowledged that while voluntary bundling models may be subject to cherry-picking of less complex patients, data revealed that "it does not fully account for associated savings."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Bundled care removes patient control / choice of the health provider they prefer. I don't care that it may be cost effective, it removes the patient from deciding on who to see for the health care treatments. Bundled Care is a first step in Hospitals and Large Corporations forming partnerships with Surgeons to isolate health care dollars to their pockets. Hospitals and Large Corporations do not care about the patient or quality of care, they only care about reimbursement.

      Posted by Bruce Linder on 1/8/2020 10:06 PM

    • The Rothman Orthopedic group based in Philadelphia but also in NJ, DE and now in NYC has stopped sending ANY patients that receive TKA's or THA's for ANY PT so they can keep the entire bundled payment for themselves. They claim they have studies that show that their patients that get NO therapy do just as well as those that do.

      Posted by Mark Reitz on 1/9/2020 4:57 PM

    • I disagree with the statement that bundled care removes patient control. That is a sweeping statement that may be facility specific. We have had great success bundled care but that has come with establishing good communication with hospital departments as well as community partners to reinforce accountability. It has helped facilitate a proactive, not reactive continuum of care. Our community HH agencies have seen more patients that need to be in care as opposed to those that really did not need to be. High volume and very high volume centers thrive in organized systems. Patient outcomes and satisfaction favor everyone working together. I feel bad that some are seeing Bundled Care in a negative light but that has not been our experience.

      Posted by Alisa Curry on 1/9/2020 5:25 PM

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