Will Bundled Payments Lead to Health-Care Rationing?: Commentary on an article by Michele D’Apuzzo, MD, et al.

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Most total joint surgeons in the U.S. are now participating in a bundled payment program for joint replacement, which means that hospitals and physicians are penalized for unplanned readmissions within “the episode of care,” which is usually 30 days after surgery. The concept behind a bundled payment to lower health-care costs is based on the assumption that bundling payments incentivizes health-care workers to work together more effectively to improve quality of care and reduce complications associated with modifiable risk factors such as obesity, diabetes, smoking, malnutrition, and some aspects of cardiac disease. Some type of risk stratification (i.e., identification of patients with modifiable or nonmodifiable risk factors associated with the development of complications) is employed to allocate more health-care resources to high-risk patients. However, the most appropriate method for stratifying these risk factors has not been established, and bundled payment systems generally do not allow high-risk patients to be excluded from the bundle.
In a study by D’Apuzzo et al. using a large statewide administrative database, the rate of 30-day readmissions due to total knee arthroplasty (TKA)-specific complications—i.e., any of 8 diagnoses defined by the Centers for Medicare & Medicaid Services (CMS) as TKA-specific or any of an expanded list of 22 TKA-specific diagnoses—was compared with the 30-day readmission rate due to all causes. The authors found that a high proportion of readmissions within 30 days after TKA are not related to diagnoses specific to TKA. Prior studies have shown patients with comorbidities and nonmodifiable risk factors to have higher 30-day readmission rates after total joint arthroplasty1. Although the database employed by D’Apuzzo et al. cannot be used to determine if the patients who were readmitted for non-TKA-specific complications also had a high rate of modifiable or nonmodifiable risk factors, the study findings and a large body of published literature related to this topic certainly suggest that this association is not unlikely.
The authors also found that the rate of readmissions for TKA-specific complications remained relatively constant from 1997 to 2014. This observation as well as the high rate of readmissions for non-TKA-specific complications suggest that the current bundled payment model may not be effective in reducing the 30-day readmission rate. Alternatively, high-risk patients can be excluded from receiving surgical treatment associated with a high rate of readmission. Exclusion of high-risk patients, or health-care rationing, is not new and has been utilized in nationalized health-care systems, although it generally is not well accepted by patients or health-care providers2-4.
The study has limitations, particularly since it is based on an administrative database so that clinical information is limited and data collection is based on diagnoses and procedure codes. However, the findings demonstrate the importance of not only risk stratification, but also an effective plan for allocation of health-care resources to all patients in need of TKA, including those who experience unplanned readmission for complications that are not specific to TKA. It is not clear how punitive measures aimed at health-care providers in bundled payment programs will help the delivery of high-quality care to high-risk patients.
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