Characteristics of Hospitals Exiting the Newly Voluntary Comprehensive Care for Joint Replacement Program

In 2018, Medicare made participation in the Comprehensive Care for Joint Replacement (CJR) program, which had been mandatory for all hospitals in 67 metropolitan statistical areas (MSAs), voluntary in the 33 of 67 MSAs with the lowest historical costs. The CJR program was designed to hold hospitals accountable for the cost and quality of care during hip or knee replacement episodes, defined as hospitalization and 90 days of postdischarge care. We compared hospitals that stayed with the CJR program against those that withdrew. This information is important for understanding the effects of voluntary payment models.

We used Medicare fee-for-service claims data for all enrollees receiving major lower-extremity joint replacements in 2015, as well as the Centers for Medicare and Medicaid Services Provider of Service files and Provider Specific files,¹ and the Hospital Compare² data set to describe each hospital’s characteristics in the first year of CJR program participation, 2016. We compared hospital characteristics using χ² and t tests. We also estimated the association of each hospital characteristic with the likelihood of CJR exit using logistic regressions adjusting for MSA-level characteristics (eAppendix in the Supplement). We then calculated the marginal effect of each hospital characteristic and presented percentage-point changes in the likelihood of CJR exit associated with each hospital characteristic. We considered 2-tailed P < .01 to be statistically significant.

Of 280 hospitals in the 33 voluntary MSAs, 205 (73%) left the CJR program in 2018 (Table). Compared with hospitals remaining in the program, hospitals that left had a higher proportion of nonwhite (9.3% vs 16.2%; P = .005) and Medicaid-enrolled (5.1% vs 11.8%; P = .002) patients. Hospitals that left the program were also more likely to have a low volume of joint replacements (12.0% vs 31.7%; P < .001) compared with hospitals that remained in the program.

Under the CJR program, exiting hospitals performed worse than hospitals that remained in the program did. Patients at exiting hospitals had longer hospital stays (3.2 vs 2.6 days; P < .001), more institutional postacute care use (41.5% vs 30.7%; P < .001), and higher readmission rates (10.9% vs 8.0%; P < .005), suggesting higher CJR episode spending. Hospitals that left the program also had lower submission rates of patient-reported outcomes (19.9% vs 41.9%; P < .001) and were less likely than hospitals that remained in the program to have received reconciliation payments (46.3% vs 72.0%; P < .001). All of these associations persisted after adjusting for MSA-level factors.

Hospitals that left the CJR program when it became voluntary served a higher percentage of nonwhite and Medicaid-enrolled patients and performed poorly in the program. These hospitals may have left the program because they would be more likely to sustain financial losses by remaining in the program. However, patients at these hospitals may gain the most from improvements in care coordination.

Hospitals with a higher proportion of socially vulnerable patients might be more likely to leave the program because episode spending for these patients tends to be high owing to greater complication rates and more common use of institutional postacute care.^3-5 The CJR program cost thresholds are more restrictive for hospitals with historical costs higher than regional average rates because the threshold is a weighted average of each hospital’s historical and regional costs in the first 3 years of the program and will be entirely based on regional costs starting in 2019.

This study has limitations. Program performance in 2017 was not examined. Medicare began covering outpatient knee replacements in 2018, which may have affected hospitals’ decisions to leave the program. Our analysis is descriptive and did not examine the relative influence of hospital characteristics on the decision to leave the program. Nevertheless, we found that hospitals exiting the CJR program were those whose patients might benefit the most from improved care coordination. Our findings suggest that the wider use of voluntary value-based payment programs by Medicare is problematic and that effective strategies that result in greater hospital participation in these programs are needed.⁶

Published Online: October 22, 2018. doi:10.1001/jamainternmed.2018.4743

Correction: This article was corrected on December 3, 2018, to add an omitted funding source.

Accepted for Publication: July 23, 2018.

Corresponding Author: Hyunjee Kim, PhD, Center for Health Systems Effectiveness, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code MDYCHSE, Portland, OR 97239-3098 (kihy@ohsu.edu).

Author Contributions: Dr. Kim had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kim, Meath, Quinones, Ibrahim, McConnell.

Acquisition, analysis, or interpretation of data: Kim, Meath, Grunditz, Ibrahim.

Drafting of the manuscript: Kim.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kim, Meath, Grunditz.

Obtained funding: Kim, Ibrahim.

Administrative, technical, or material support: Kim, Meath.

Study Supervision: Kim, McConnell.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Ibrahim is supported in part by a K24 Mid-Career Development Award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (K24AR055259). This research was also funded by National Institutes of Health grant 5R01MD011403-02.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not represent those of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, or the National Institutes of Health.