A new study published in the February issue of Health Affairs confirms what many would have expected: that patient and cost outcomes for joint replacement (hip and knee) surgeries have proven to be lower among the nation’s safety-net hospitals than among non-safety-net hospitals, raising the possibility that the mandatory Comprehensive Care for Joint Replacement (CJR) program under Medicare could further fragilize already financially vulnerable safety-net facilities nationwide.
The article, entitled “Performance Of Safety-Net Hospitals In Year 1 of the Comprehensive Care for Joint Replacement Model,” was authored by a team of researchers: Caroline P. Thirukumaran, Laurent G. Glance, Xueya Cai, Rishi Balkissoon, Addisu Mesfin, and Yue Li. As the authors note, “The Comprehensive Care for Joint Replacement (CJR) model introduced in 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study we used Medicare’s CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals’ rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend could place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients could enable safety-net hospitals to compete effectively in CJR.”
In fact, the authors note, “While different target prices are set based on Medicare Severity Diagnosis-Related Groups (MS-DRGs), CMS does not adjust a hospital’s target price for other health risks or social risk. Because of this, safety-net hospitals that care for disproportionate numbers of vulnerable patients (patients with high medical and social needs) are likely to fare poorly under CJR.” Indeed, “The odds of safety-net hospitals’ having below-acceptable performance were 3.56 times those for hospitals in quintile 1. Consequently, safety-net hospitals had lower odds of receiving financial rewards. And, the researchers underscore, safety-net hospitals care for sicker patients, and higher proportions of their patients are socioeconomically disadvantaged and members of racial minority groups. “These patients lack robust social support systems and are less likely to adhere to prescribed treatment regimens. Consequently, patients in safety-net hospitals are more likely to experience complications and have lower patient satisfaction. Second, achieving the prescribed quality benchmarks requires hospitals to make substantial investments in infrastructure and personnel to improve care quality and patients’ experiences. However, safety-net hospitals have fewer resources to allocate to quality improvement initiatives,” they add.
Ultimately, the researchers conclude, “Safety-net hospitals were less likely to receive rewards in year 1 of CJR because of their quality and spending performance. Continuation of this trend into subsequent years will place these hospitals at higher risk of CJR penalties. Strategies that address the added complexity of patients treated in safety-net hospitals are necessary to reduce the disadvantage of safety-net hospitals and the vulnerable patients they serve.”
