Identifying the “Bundle Busters” in Total Joint Arthroplasty Payment Models

    With the advent of bundled payment models for total joint arthroplasty, surgeons need to be cognizant of the “bundle busters” – the excessive costs incurred in the bundle that can jeopardize the surgeon’s (and the hospital’s) financial health.

    During a session on economics in joint replacement at the 7th Annual ICJR South Hip & Knee Course, R. Michael Meneghini, MD, from the Indiana University School of Medicine in Indianapolis, reviewed recent studies on bundled payments that give surgeons insight into the issues that can arise and point to real-world solutions that can help keep bundle busters under control.

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    He cited a 2018 study from surgeons at The Rothman Institute, who found that in the 90-day period after discharge, 3.3% of total hip arthroplasty (THA) patients and 2.6% of total knee arthroplasty (TKA) patients had an emergency department visit and 2.6% of THA patients and 3.7% of TKA patients were readmitted to the hospital for complications following surgery. [1]

    Using this data, Dr. Meneghini said, the surgeons were able to identify their post-discharge bundle busters, which were different for THA and TKA patients:

    • The 3018 THA patients experienced predominantly joint-related complications (43.9%), including dislocation, periprosthetic fracture, and wound complications.
    • Costs for these complications ranged from $28,889 for a dislocation to $39,684 for a periprosthetic fracture.
    • The 5389 TKA patients experienced predominantly medically related complications (59.7%). Chief among them was myocardial infarction (4%). Another 29.7% of complications were joint-related.
    • The cost to manage a patient who experienced a myocardial infarction following TKA discharge was $29,874. Many of the joint-related complications were more expensive – for example, $61,553 for a perioprosthetic joint fracture – but the greater number of myocardial infarctions compared with joint-related complications made it the most-costly complication of TKA.

    Emergency department visits are often cited as a “bundle buster,” but in this study, they did not significantly contribute to the post-dishcarge costs for THA or TKA patients, Dr. Meneghini said. [1]

    One of the most comprehensive studies on proactively managing potential bundle busters is a 2017 paper from NYU Langone Health, Dr. Meneghini said. [2] The study discusses the 5 “pillars” of care that NYU Langone Health surgeons had adopted to help them manage their joint replacement patients when they implemented a bundled payment initiative. This includes:

    • Carefully selecting patients and optimizing their comorbidities preoperatively
    • Offering expanded patient education, managing patient expectations, and providing care coordination and shared decision making
    • Developing a multimodal pain management protocol that minimizes opioid use
    • Establishing a blood conservation protocol and DVT risk stratification, as well as minimizing aggressive anticoagulation
    • Minimizing the use of post-acute care facilities and resources

    More information about the NYU Langone Health experience can be found here.

    Click the image above to hear more about bundle busters, including Dr. Meneghini’s experience at his institution.

    Disclosures: Dr. Meneghini has no disclosures relevant to this presentation.


    1. Luzzi AJ, Fleischman AN, Matthews CN, Crizer MP, Wilsman J, Parvizi J. The “bundle busters”: incidence and costs of postacute complications following total joint arthroplasty. J Arthroplasty. 2018 Sep;33(9):2734-2739. doi: 10.1016/j.arth.2018.05.015. Epub 2018 Jun 11.
    2. Kim K. Iorio R. The 5 clinical pillars of value for total joint arthroplasty in a bundled payment paradigm. J Arthroplasty. 2017 Jun;32(6):1712-1716. doi: 10.1016/j.arth.2017.02.012. Epub 2017 Feb 14.