Abstract
As more commercial insurance companies adopt a bundled reimbursement model, similar
to the Comprehensive Care for Joint Replacement (CJR) algorithm for Medicare beneficiaries,
accurate risk adjustment of patient-reported outcomes (PROs) is critical to ensure
success. With this movement toward bundled reimbursement, it is unknown if a formula
adjusting for similar risks in the Medicare population could be applied to PROs in
commercially insured and Medicare Advantage populations undergoing total knee arthroplasty
(TKA). This study was performed to compare PROs after TKA in these insurance groups
after adjusting for proposed risks. Demographics and clinical data were abstracted
from medical records of 302 patients who underwent TKA performed by a single surgeon
at a university-based orthopaedic practice during 2013 to 2017. Differences in PROs
between commercially insured, Medicare Advantage, and Medicare patients during the
6 months following surgery were evaluated while controlling for demographics, clinical
data, and baseline PRO scores. Medicare and Medicare Advantage patients were older
(p < 0.001) and had more comorbidities (p = 0.001) than commercial patients. During the first 3 months following TKA, patients
in all three groups experienced similar rates of recovery. At 6 months after surgery,
outcomes began to diverge by insurance group. Medicare patients reported significantly
less ability to perform activities of daily living (78.6 vs. 63.2; p = 0.001), worse physical function (39.6 vs. 44.9; p = 0.003), and more pain interference (57.9 vs. 52.4; p = 0.018) at day 180 than commercially insured patients. There were no statistically
significant differences between Medicare Advantage patients and either commercially
insured or Medicare patients. Therefore, commercial insurance companies that intend
to apply a risk-adjusted equation similar to the CJR algorithm to commercial populations
should be cautioned since the postoperative outcomes in this investigation differed
after adjusting for the same risk factors that have been proposed for inclusion in
the CJR algorithm. Nonetheless, further studies should be performed to ensure that
companies participating in bundled reimbursement models have a positive influence
on comprehensive health care for patients and providers. This is a level III, retrospective
prognostic study
Keywords
arthroplasty - knee - outcomes - insurance
