Does Bundled Care Discriminate Against Older Frail Patients?

A new, first-of-its-kind research has found that the Bundled Payment Care Improvement (BCPI) program likely DID discriminate against older, frail patients.

The study that raised this issue and looked at the data is titled “Age and Frailty Influence Hip and Knee Arthroplasty Reimbursement in a Bundled Payment Care Improvement Initiative,” and appears in the January 29, 2019 edition of The Journal of Arthroplasty.

Co-author Richard Iorio, M.D., chief of Adult Reconstruction and Total Joint Arthroplasty Service and vice chairman of Clinical Effectiveness at Brigham and Women’s Hospital and Harvard Medical School faculty member told OTW, “Our findings are the first to directly evaluate the effects of simple patient factors, such as age and frailty, on episode cost in a BPCI initiative. Currently, the BPCI initiative does not take into consideration patient age and modifiable and nonmodifiable risk factors into determining payment for TJA.”

“The cost for care in the BPCI initiative is determined by a variety of factors.”

“In early BPCI models cost of care considered were historical cost data, regional data supplements to unavailable historical cost data, episode costs were trended compared to national episode-specific growth rates, with discounts applied depending on model participation.”

“Although many multiple considerations contribute to cost determination in the early BPCI models, there was no episode cost stratification based on individual patient demographics, including age or patient-specific risk factors.”

“The greater question raised by this discussion is the structure of bundled payment models, which assume cost of care as a fixed value based on over-simplified estimates of cost of care for TJA [total joint arthroplasty].”

“This ignores the fact that patients are, by nature, not equivalent and that appropriate care requires an individualized approach to achieve consistent quality of care. This includes careful thorough perioperative evaluation, risk factor identification and optimization, surgical planning, varying degrees of surgical technique/equipment for increasing complexity, and differing implant selection.”

“Without addressing the lack of patient-specific cost consideration in current APMs [alternative payment models], we are destined to develop institutionalized discrimination in care quality and access, specifically for patients who require the expertise of well-trained arthroplasty surgeons.”

“This situation amounts to national institutionalized cherry picking which has the potential to perpetuate care discrimination.”

“When age was evaluated as an independent continuous variable, our data revealed an increase cost per care episode of 0.68%, or $217, for each incremental year increase in age (95% confidence interval 0.47-0.89).”

“In a multivariate linear regression model evaluating both age and frailty (using the modified Frailty Index score), the data revealed a statistically significant (P < .01) incremental increasing cost of care for both continuously increasing age and frailty score, except for a frailty score of 1 (P ¼ 0.06).”

“Although the goal of the BPCI initiative is to decrease cost and improve the quality of care, the current pricing scheme oversimplifies the cost associated with TJA. Further research in this area and refinement of pricing metrics is advisable to better estimate the cost associated with TJA and continue to drive value and quality of care in the U.S. healthcare system.”

“We demonstrate in this study that simple patient factors such as age and frailty significantly affect the cost of care and reimbursement in a BPCI initiative for TKA and THA. At present, there is no patient-specific cost consideration to account for these differences in current bundled payment models. This information demonstrates that further study is required to better elucidate cost considerations for arthroplasty patients.”