Joint replacement pay reform hasn't hurt Alzheimer's patients

Medicare payment reforms for joint replacement didn't increase disparities in use between patients with Alzheimer's and those without, according to a new study in JAMA Health Forum on the first two years of program data.

The findings, published Friday, came after previous studies found the value-based payment reform was associated with a decrease in knee replacements for Black beneficiaries and dual-eligible beneficiaries. The relatively equitable treatment for Alzheimer's patients under the reformed model is encouraging, but policymakers should keep evaluating new models to make sure they're offering equitable care to vulnerable populations, the study's authors wrote.

Hip and knee replacements are the most common inpatient surgical procedures for Medicare beneficiaries, which makes them a natural target for the Center for Medicare and Medicaid Innovation's payment reforms.

One such program, the Comprehensive Care for Joint Replacement model, bundles payment for a joint replacement as a way to control the costs of these procedures and improve their quality. The model, which began in 2016 and stretches until 2024, proved in at least its first two years to lower joint replacement costs without compromising quality across the general Medicare population.

But prior studies have found the model widened gaps in knee replacement rates between white and Black Medicare beneficiaries, and contributed to socioeconomic disparities.

This prompted a look into the model's impact on Alzheimer's patients, led by Caroline Thirukumaran, an assistant professor at the University of Rochester Medical Center who conducted a previous study on the model's impact on Black and dual-eligible patients. Thirukamaran and her co-investigators hypothesized that the model could increase disparities for beneficiaries with Alzheimer's as well.

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Alzheimer's disease—the most common cause of dementia—is projected to affect 7.2 million people by 2025, representing a nearly 16% increase from the disease's prevalence in 2021, according to a report from the Alzheimer's Association. The association estimated dementia would cost Medicare $181 billion in 2021.

Alzheimer's patients experience cognitive and physical decline, so they typically require more costly institutional post-acute care for joint replacements—one area where providers have cut costs in this model, the study says. Beneficiaries with Alzheimer's also have been shown to have higher mortality and complication rates.

However, the researchers found that the gap in replacements between beneficiaries with and without Alzheimer's did not widen significantly in the two years after the payment reform went into effect.

There is some evidence to suggest that beneficiaries who'd recently been diagnosed with Alzheimer's received less knee replacements than they would have outside the new model, but these findings warrant further research, the authors said.

"Given these mechanisms, our finding that the CJR model did not disproportionately worsen joint replacement use for beneficiaries with [Alzheimer's and related dementias] is reassuring," the study says.

Dr. Adam Rana, a Maine-based orthopedic surgeon and advocacy chair of the American Association of Hip and Knee Surgeons, said the payment reform has allowed surgeons to better identify complication risks in vulnerable patients before surgery, and then take steps to mediate them.

"I think one thing that is reassuring that with value based care models is that we're we're still maintaining access for a higher risk groups, because we're putting more weight on the preoperative work and optimization that goes on to maintain access care for individuals," he said.

Still, the findings contribute to a growing call for the Centers for Medicare and Medicaid Services to better adjust value-based care models to account for social risk. Providers caring for vulnerable populations may require more or different resources to reach the same performance standards as their peers caring for more advantaged groups. Conversely, some say this could lead to a two-tiered system of care where providers for less-advantaged groups can get away with delivering worse care, Dana Gelb Safran and Jonathan Jaffery, both commissioners on the Medicare Payment Advisory Commission, wrote in a Health Affairs article last spring.

The Comprehensive Care for Joint Replacement model now adjusts for social risk factors including hierarchical condition category, age and dual eligibility. This could alleviate some of the overall decline in hip replacements correlated with the model and the dip in knee replacements for newly-diagnosed Alzheimer's patients, the researchers write. But stakeholders should pay more attention to other vulnerable populations and how they fare in value-based payment reforms.

"Despite being well intended, these reforms may unintentionally limit care for vulnerable patient populations... continual monitoring of these reforms will ensure that beneficiaries with [Alzheimer's] and other vulnerable patients receive equitable and effective care," the study reads.