Association of Medicare Bundled Payment Model With Joint Replacement Care for People With Dementia

Hyunjee Kim PhD; Cesar A. Juarez MS; Thomas H. A. Meath MPH; Ana R. Quiñones PhD; Joan M. Teno MD


J Am Geriatr Soc. 2022;70(9):2571-2581. 

In This Article

Abstract and Introduction


Background: We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery.

Methods: Retrospective cohort study using 2013–2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge.

Results: Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean SD age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] −$1577, −$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI −3.17, −0.07, p = 0.04), but no changes in 90-day readmission (95% CI −2.68, 0.00, p = 0.051).

Conclusions: Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.


About 6 million Americans had Alzheimer's disease and related dementia (ADRD) in 2020 and the number is projected to increase to 14 million by 2060.[1,2] People with ADRD experience declines in cognition and physical functioning and can present care delivery challenges, particularly around invasive surgical procedures. As Medicare introduces value-based payment models designed to improve the quality of surgical care and subsequent rehabilitation, understanding the effects of these changes on this medically complex population is critical.

The Comprehensive Care for Joint Replacement (CJR) model, Medicare's mandatory bundled payment model for joint replacements, may have significantly affected persons with ADRD. In April 2016, the Center for Medicare and Medicaid Services (CMS) implemented the CJR model in 67 randomly selected metropolitan statistical areas (MSAs) and most hospitals in those MSAs were required to participate. The CJR model set a quality-adjusted spending benchmark for each hospital's joint replacement episode, defined as the index hospitalization and 90-day post-discharge care. If a hospital's actual spending is below the benchmark, the hospital receives a bonus; otherwise, they pay a penalty. Until October 2021, CJR did not adjust for patient comorbidities (other than the presence of a hip fracture or major complications during the index hospitalization) when setting the spending benchmark for each hospital.[3] Therefore, CJR could have encouraged hospitals to avoid providing costlier patients—such as those with ADRD—with joint replacements.

Hip fracture and severe arthritis are common among people with ADRD.[4,5] People with ADRD typically have more risk factors for hip fracture (e.g., gait impairment, osteoporosis, and depression) and the incidence of hip fracture is 2–3 times higher for patients with ADRD.[5,6] Many Medicare enrollees with ADRD receive joint replacement each year, representing about 7% of all joint replacements paid by Medicare's fee-for-service program. The majority (63%) of these procedures occur after hip fracture, with 37% being elective, whereas the hip-fracture percentage for people without ADRD is lower (11% hip fracture vs. 89% elective).

Evidence suggests that joint replacements can still be beneficial for people with ADRD.[7] However, people with ADRD can present additional challenges to care delivery. People with ADRD are at greater risk for delirium after surgery, which results in slow recovery and longer hospital stays.[8,9] People with ADRD are also more likely to experience complications after joint replacements.[10,11] Furthermore, rehabilitation can be difficult due to cognitive impairment.[12,13] These challenges can lead to higher spending for joint replacements and after recovery among people with ADRD. Based on our data, spending on joint replacement surgery and 90-day rehabilitation for people with ADRD was about 10%–16% higher than for the general patient population.[14]

Due to anticipated higher spending, the CJR model may have discouraged hospitals from providing not only elective joint replacement but also post-hip-fracture joint replacement for people with ADRD. Hospitals rarely refuse or delay joint replacements for patients with a hip fracture because replacement surgery is generally considered the best treatment option after hip fracture.[15,16] However, people with ADRD are sometimes an exception and may receive palliative care after hip fracture instead of surgical repair.[7]

The CJR model may have also influenced postsurgical care for people with ADRD. Prior studies concluded that among the general patient population, CJR was associated with an increased percentage of people who went home after surgery, instead of being discharged to an institutional post-acute care setting. On average, despite receiving less intense post-acute care, postsurgical outcomes remained the same.[14,17–20] The CJR model may have similar implications for people with ADRD. For example, hospitals may steer patients with ADRD from expensive institutional post-acute settings to home-based care. At the same time, however, patients with ADRD may obtain similar postsurgical outcomes if hospitals successfully improve care coordination.

Using the complete set of 2013–2017 Medicare claims and Minimum Data Set, we evaluated whether the CJR model was associated with the receipt of joint replacements in Medicare enrollees with ADRD. Among those who received a joint replacement, we also assessed the association of the CJR model with spending, health service use, and postsurgical outcomes. Our study provides critical information about the impact of Medicare value-based payment reforms on care for people with ADRD.