The Ways We Pay: Orthopaedics Researchers to Study Impact of Medicare Reform on Patient Care

Researchers from the University of Rochester Medical Center (URMC) will determine whether a new Medicare payment model has deepened racial and socioeconomic disparities in joint replacement care with new funding from the National Institutes of Health. Racial and socioeconomic disparities, especially among older Medicare beneficiaries, are well-documented in joint replacement care and the researchers worry this well-meaning reform could make things worse.

The Centers for Medicare and Medicaid Services introduced the Comprehensive Care for Joint Replacement Model in April of 2016 to improve coordination and quality of medical care for joint replacements. The model bundles all joint replacement care - from surgery to rehab - into a single payment, holding hospitals financially accountable for the quality and cost of care across that spectrum.

“The bundled payment model may motivate hospitals to adopt measures that could worsen racial and socioeconomic disparities of hip and knee replacement surgery utilization and outcomes,” said Caroline P. Thirukumaran, M.B.B.S., M.H.A., Ph.D., assistant professor of Orthopaedics, Public Health Sciences, and in the Center for Musculoskeletal Research (CMSR) at URMC. “Reducing the length of stay or discharging patients to home instead of a skilled nursing facility, for example, may reduce costs, but may not be sensitive to the unique needs of underrepresented patients.”

Thirukumaran, who will lead the study, also believes the bundled payment reform could hurt safety net hospitals, which care for a high proportion of racial minorities and low socioeconomic status patients who are in poorer health. These hospitals also have fewer resources to invest in quality improvement. Without specific measures to account for patient risk, these hospitals will likely perform poorly on the new model’s benchmarks, thereby worsening care for their vulnerable patients.

With this $1.5 million, 4 year grant from NIH, Thirukumaran will analyze national Medicare data to see if bundled payment reforms had an impact on racial and socioeconomic disparities among patients undergoing hip and knee replacements. She also hopes to pinpoint which health care decisions contribute to the disparities, such as rehab facility choice, to ultimately inform policy. Adding specific language, incentives, and measures to reduce disparities in health care access and outcomes to the bundled payment reform may be a viable first step.

This is the first population health grant from the NIH ever awarded to the URMC Department of Orthopaedics and CMSR, which has been among the top five NIH-funded orthopaedic research centers in the nation for over ten years. Thirukumaran’s co-investigators on this collaborate project include: Yue Li, Ph.D., professor of Public Health Sciences; Laurent G. Glance, M.D., professor of Anesthesiology & Perioperative Medicine; Xueya Cai, Ph.D., research associate professor of Biostatistics and Computational Biology; Addisu Mesfin, M.D., associate professor of Orthopaedics; and Rishi Balkissoon, M.D., M.P.H., assistant professor of Orthopaedics.