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How a Medicare payment model is affecting care for older adults with Alzheimer's disease and related dementias

Older adults with Alzheimer's disease and related dementias (ADRD) who need joint replacement may not undergo surgery because their ADRD may be considered a contraindication. Not only that, older adults with ADRD (compared to those without) are more likely to experience costly postsurgical complications, such as delirium, prolonged length of stay, and functional impairment. Policies that may impact provisions for older adults with ADRD, like the Comprehensive Care for Joint Replacement (CJR) Model, should be evaluated to ensure appropriate care. Starting in 2016, the CJR Model was developed to reduce spending while maintaining or improving the quality of postsurgical care for joint replacements. In the Model, postsurgical care provided by clinicians, such as in skilled nursing facilities (SNF), is paid for as part of a 90-day bundle. Outside of Model-participating hospitals, such care is paid for separately. Given that hip and knee replacements are costly and the most common surgeries for Medicare, the rationale for bundling payments within the CJR Model is to incentivize hospitals to decrease expenditures while being held financially accountable to maintain or improve quality of care. There may be concern that bundled payments could lead to “cherry-picking” of healthier patients less likely to incur high expenditures after surgery; however, this has not been demonstrated in a prior study evaluating the impact of the CJR Model on the receipt of joint replacement across all Medicare patients. Still, it is possible that the CJR Model could lead to “cherry-picking” in patients with ADRD because of the burden of postsurgical complications. This issue's study by Kim and colleagues addresses this concern and sheds light on the impact of the CJR Model on older adults with ADRD. Using Medicare administrative claims data from 2013 to 2017 and applying a differences-in-differences analysis, the authors compared the number of joint replacements per 1000 enrollees per quarter in older adults with ADRD residing in Model-participating areas versus non-participating areas, and found no association between the CJR model and receipt of joint replacement. This finding did not change when stratifying by type of joint replacement surgery—elective knee replacement, elective hip replacement, or post-fracture hip replacement. Even among more medically complex ADRD subpopulations, such as nursing home (NH) residents and NH residents with severe cognitive and/or functional impairments, the CJR model was not found to have an impact on the receipt of joint replacement. This study also assessed the impact of the CJR Model on Medicare spending and different types of healthcare resource use (i.e., institutional post-acute care, home health, and hospice) among older adults with ADRD who received surgery. The CJR Model led to a modest reduction in total spending ( $1029 per episode, 95% confidence interval [CI]: $1577 to $481) in older adults with ADRD who received surgery. This reduction in spending was primarily driven by fewer discharges to and days spent in post-acute care settings ( 1.62% discharges, 95% CI: 3.17% to 0.07% and 1.79 days among those discharged to institutional post-acute care settings, 95% CI: 2.89 to 0.70, respectively). When comparing spending on types of post-acute care settings, the reduction in spending was largely driven by decreased spending on SNF ( $754 per episode, 95% CI: $1164 to $345). When examining the subpopulations who received an elective joint replacement versus those with a postfracture hip replacement, both subpopulations had reduced spending ( $1375 per episode, 95% CI: $2125 to $624 in those with elective joint replacement and $1063 per episode, 95% CI: $1825 to $300 in those with post-fracture hip replacement) after the CJR Model was implemented. However, only patients who received elective joint replacement surgery were less likely to be discharged to post-acute care settings ( 4.01% discharges, 95% CI: 7.1% to 0.92% among those with elective surgery versus 1.01% discharges, 95% CI: 2.7% to 0.68% among those post-fracture), suggesting that post-acute care was necessary after fracture. When comparing ADRD patients seen at hospitals participating versus not participating in the CJR Model, there were no differences across postsurgical outcomes, including functional status, 90-day readmissions, 90-day emergency department use, and 90-day mortality. In subpopulations, This Editorial comments on the article by Kim et al. in this issue. Received: 10 June 2022 Accepted: 15 June 2022