Dataset Information

Safety-net hospital performance under Comprehensive Care for Joint Replacement.

ABSTRACT:

Objective

To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program.

Data sources/study setting

Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association.

Study design

We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time.

Principal findings

Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non-SNHs. The contribution of nurse staffing was negligible across all CJR hospitals.

Conclusions

The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.

SUBMITTER: Carey K

PROVIDER: S-EPMC9836942 | biostudies-literature | 2023 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Safety-net hospital performance under Comprehensive Care for Joint Replacement.

Carey Kathleen K Lin Meng-Yun MY

Health services research 20220809 1

<h4>Objective</h4>To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program.<h4>Data sources/study setting</h4>Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association.<h4>Study design ...[more]

PMID: 35904218

Similar Datasets

Project description:ImportancePrior research concluded that institutional postacute care spending decreased under the Comprehensive Care for Joint Replacement (CJR) model. Less is known about how changes in institutional postacute care spending varied across different types of hospitals.ObjectiveTo measure hospital-level heterogeneity in the association of the CJR model with changes in institutional postacute care spending and to identify hospital characteristics associated with this variation.Design setting and participantsUsing 100% Medicare claims data, this cross-sectional study assessed institutional postacute care spending from 2016 to 2017 among US hospitals randomly selected to participate in the CJR model and control group hospitals that were eligible but not selected for the participation in the CJR model. A causal forest was used to estimate the treatment effect of the CJR model conditional on hospital characteristics. Analysis was conducted between October 2019 and October 2021.Main outcomes and measuresThe unit of analysis was each hospital; the outcome was the average per-episode Medicare spending for institutional postacute care within 90 days after hospital discharge for hip or knee joint replacement.ResultsThis study included 531 CJR participating hospitals and 658 control group hospitals from 2016 to 2017. The CJR model was associated with a $761 reduction in institutional postacute care spending (95% CI, -$1172 to -$351). The reduction in spending under the CJR model did not vary across conditional on hospital characteristics. Limited evidence was found for greater savings among hospitals with higher pre-CJR spending. However, this finding did not hold for hospitals in the highest quintile of pre-CJR spending.Conclusions and relevanceIn this cross-sectional study of 1189 hospitals, findings did not show strong evidence for significant heterogeneity in how the CJR model was associated with reductions in institutional postacute care spending across a range of hospital characteristics. Savings were not concentrated in hospitals with specific characteristics, such as hospitals with high-volume joint replacement or hospitals serving less medically or socially complex patients. Findings suggest that the CJR model created opportunities for savings across a spectrum of different hospitals.

Project description:BackgroundThe Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction penalties on acute care hospitals with higher-than-expected readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. There is concern that hospitals serving large numbers of low-income and uninsured patients (safety-net hospitals) are at greater risk of higher readmissions and penalties, often due to factors that are likely outside the hospital's control. Using publicly reported data, we compared the readmissions performance and penalty experience among safety-net and non-safety-net hospitals.MethodsWe used nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. We identified as safety-net hospitals the top quartile of hospitals in terms of the proportion of patients receiving income-based public benefits. Using a quasi-experimental difference-in-differences approach based on the comparison of pre- vs. post-HRRP changes in (risk-adjusted) 30-day readmission rate in safety-net and non-safety-net hospitals, we estimated the change in readmissions rate associated with HRRP. We also compared the penalty frequency among safety-net and non-safety-net hospitals.ResultsOur study cohort included 1915 hospitals, of which 479 were safety-net hospitals. At baseline (2009), safety-net hospitals had a slightly higher readmission rate compared to non-safety net hospitals for all three conditions: AMI, 20.3% vs. 19.8% (p value< 0.001); heart failure, 25.2% vs. 24.2% (p-value< 0.001); pneumonia, 18.7% vs. 18.1% (p-value< 0.001). Beginning in 2012, readmission rates declined similarly in both hospital groups for all three cohorts. Based on difference-in-differences analysis, HRRP was associated with similar change in the readmissions rate in safety-net and non-safety-net hospitals for AMI and heart failure. For the pneumonia cohort, we found a larger reduction (0.23%; p < 0.001) in safety-net hospitals. The frequency of readmissions penalty was higher among safety-net hospitals. The proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net and 59% among non-safety-net hospitals.ConclusionsOur results lend support to the concerns of disproportionately higher risk of performance-based penalty on safety-net hospitals.

Project description:Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

Project description:ObjectiveTo determine whether the Comprehensive Care for Joint Replacement (CJR) model, a mandatory episode-based payment program for knee and hip replacement surgery, affected patient-reported measures of quality.Data sourcesSurveys of Medicare fee-for-service beneficiaries who had hip or knee replacement surgery, collected between July 2018 and March 2019, secondary Medicare administrative data, the Provider of Services file, CJR and Bundled Payments for Care Improvement participant lists from the Centers for Medicare & Medicaid Services, and the Area Health Resource Files.Study designIn 2018, participation in the CJR model was mandatory for nearly all hospitals in 34 randomly selected, metropolitan statistical areas (MSAs) that had high historical Medicare payments for lower-extremity joint replacements surgery. The control group included 47 high-payment MSAs randomly assigned as controls. We estimated risk-adjusted differences in self-reported measures of functional status and pain, satisfaction with care, and caregiver help between respondents in CJR hospitals and respondents in hospitals located in the control group.Data collectionWe selected a census of CJR patients and an equal number of control patients to survey. We fielded two waves of surveys using a mail and phone protocol, yielding 8433 CJR and 9014 control respondents.Principal findingsCJR respondents were slightly more likely to depend on caregivers for certain activities of daily living when they got home (either directly from the hospital or after an institutional post-acute care stay). On a 100-point scale, differences ranged from -2.6 points (p < 0.01) for help needed bathing to -1.7 points (p < 0.05) for help needed using the toilet. However, differences in eight measures of self-reported functional status approximately 90-120 days after hospital discharge were not statistically significant, ranging from -1.1% (p = 0.087) to 0.7% (p = 0.437).ConclusionsCJR did not harm patient health or affect patient satisfaction on average but did increase reliance on caregivers during recovery.

Project description:BackgroundThe Comprehensive Care for Joint Replacement (CJR) model is an alternative Medicare payment model for joint replacement that mandated participation by hospitals in randomly selected Metropolitan Statistical Areas (MSAs). On average, the program decreased inpatient length of stay and increased home discharge rates. It is unclear if these effects differed based on hospital ownership type, even though ownership may impact care redesign opportunities.MethodsWe used the 2014-2017 California Patient Discharge Datasets. The study included 113,590 hospitalizations for hip and knee joint replacement from 287 hospitals in the treated and control MSAs in California. The primary outcomes were inpatient length of stay and home discharge rates. Home discharge status included self-care, the use of home health, and hospice care at home. To determine whether the impact of the CJR model differed by hospital ownership type, we used event study, difference-in-differences (DID), and triple differences (DDD) models to estimate changes in health care services utilization in treated relative to control areas before versus after CJR implementation (April 2016) by hospital ownership type.ResultsOf the 113,590 hospitalizations, 51,708 (45.52%) were in treated MSAs and 61,882 (54.48%) were in control MSAs; 81,649 (71.88%) were from nonprofit hospitals, 20,247 (17.82%) were from for-profit hospitals, and 11,694 (10.29%) were from government-owned hospitals. DID analyses showed that after policy implementation, nonprofit and for-profit hospitals experienced a decrease in inpatient length of stay of 0.02 days (95% CI, -0.04 to -0.01) and 0.04 days (95% CI, -0.06 to -0.01), respectively, while government-owned hospitals experienced an increase by 0.11 days (95% CI, 0.04 to 0.18). For home discharge rates, nonprofit hospitals experienced an increase of 0.02 (95% CI, 0.01 to 0.03), while other hospitals did not show statistically significant changes. DDD analyses confirmed that inpatient length of stay increased in public compared to nonprofit hospitals in treated relative to control MSAs after policy implementation.ConclusionsThe impacts of the CJR program differed by hospital ownership type. Government-owned hospitals, with their unique financial circumstances, may have faced challenges that hindered the reductions in inpatient length of stay observed in other types of hospitals under the CJR Model.

Dataset Information

Safety-net hospital performance under Comprehensive Care for Joint Replacement.

Objective

Data sources/study setting

Study design

Principal findings

Conclusions

Publications

Safety-net hospital performance under Comprehensive Care for Joint Replacement.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets