Association of the redesigned Comprehensive Care for Joint Replacement model with racial/ethnic and socioeconomic disparities in joint replacement surgeries

Northwestern University At Chicago, Evanston IL

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Abstract

ABSTRACT Total hip and knee replacements (“total joint replacements” [TJRs]) are highly successful surgeries for patients with end-stage arthritis. Despite their clinical benefits, racial/ethnic and socioeconomic health disparities in the use and outcomes of these surgeries are well-established. These health disparities have persisted for decades despite well-intentioned and effective disparity reduction strategies that have been locally implemented. In the absence of a national reform that incentivizes health disparity reduction, the vision of achieving high-quality TJR care for all patients may remain unfulfilled. Medicare’s 2016 Comprehensive Care for Joint Replacement (CJR) model is a bundled payment reform aimed at improving quality and reducing spending for Medicare beneficiaries undergoing TJRs. In 2021, the CJR was redesigned (rCJR) to include adjustments for economic risk (dual-eligibility for Medicare and Medicaid) and clinical risk (hierarchical condition category score and age) – measures that could potentially reduce TJR disparities by ‘recognizing’ the higher spending for certain patients (many of whom may be Black or low-income, and are in poorer health). These adjustments are likely to reduce incentives for hospitals to avoid operating on these patients, provide these patients access to high-quality hospitals, and increase quality/price competition between hospitals to attract these patients; thereby promoting TJR use and postoperative outcomes for all who will benefit from these treatments. In theory, the new risk adjustment measures could potentially transform the rCJR into a national TJR health disparity reduction strategy. However, there is little empirical evidence to support our hypothesis. Thus, our objective is to evaluate rCJR’s association with racial/ethnic and socioeconomic health disparities in TJR use, outcomes, and spending, with a focus on the performance of safety-net hospitals. We will use national Medicare data from 2018-2024 to evaluate rCJR’s association with health disparities in the use of TJRs (Aim 1) and in clinical metrics (Aim 2). We will also examine how the rCJR may have influenced TJR spending for patients from various groups (Aim 3). Our work is significant because we will answer questions such as whether the rCJR was effective in reducing health disparities, which metrics were most influenced by the rCJR, and which institutions successfully reduced disparities. These findings are critical for understanding whether and how the rCJR can be leveraged to reduce health disparities nationally, and for realizing the elusive target of ensuring high-quality TJR care for all patients with arthritis.