Matching TJA Patients with the Right Level of Post-Discharge Care

    Dr. Andrew Star discusses the demand-matching strategy used at The Rothman Institute to ensure total joint arthroplasty patients on Medicare receive the services they need in the most efficient manner possible, leading to significant cost savings without compromising outcomes.

    Even accounting for differences in costs across the country, institutions nationwide could collectively realize savings of more than $1 billion annually if they used a demand-matching strategy for post-discharge care of their total joint arthroplasty patients on Medicare, as advocated by The Rothman Institute, all without sacrificing patient care and outcomes.

    The shift from fee-for-service reimbursement to value-based payment models prompted the surgeon at The Rothman Institute to examine resource utilization among total hip and total knee arthroplasty patients. Were there alternatives to their traditional practices that could reduce costs while still providing good outcomes for their patients?

    To find out, they looked at payment data for their patients who had undergone primary unilateral total joint arthroplasty between July 2014 – the date they implemented the demand-matching strategy – and December 2016, yielding data on 5087 patients (2157 hip patients and 2930 knee patients). Payments were divided into acute care and post-discharge care, and then post-discharge payments were further subdivided into outpatient and inpatient rehabilitation. They also recorded discharge destination (home versus inpatient facility).

    The Rothman Institute had implemented a demand-matching strategy intended to ensure patients receive the services they need in the most efficient manner possible. Determining where patients should receive operative and postoperative care is based on social and clinical risk assessment that includes variables such as preoperative and postoperative functional status, overall health and comorbidities, and availability of home support after discharge. For post-discharge care, the options for rehabilitation range from outpatient physical therapy on the low end, to structured physical therapy in the home with a home health therapist, to inpatient rehabilitation on the high end, with corresponding increases in cost.

    Costs for the surgical portion of the episode of care remained stable during the study period, averaging close to $14,000 per patient. Post-discharge costs were another story, dropping steadily from about $7300 in July 2014 to nearly $4100 by the end of 2016 – a 44% decrease in post-discharge costs (P=0.000) attributed to demand-matching of patients and resources. In addition, home discharges, compared with discharges to inpatient facilities, increased from 43% to 76% during the study period (P=0.000).

    The study authors calculated that their savings of $3222 per patient would translate to more than $1 billion in savings nationwide. That’s based on 446,148 discharges for DRG 470 (total joint arthroplasty) reported by the Centers for Medicare and Medicaid Services in 2013.

    These results did not surprise the Rothman team. “It was clear from our research in the past that financial resources for post-acute care were not very carefully controlled,” said lead author Andrew M. Star, MD. “In addition, our region was very high in utilization compared with other parts of the country. The only surprise was how quickly we were able to change practice.”

    Dr. Star said that discharging patients home instead of a to a skilled nursing facility is an important goal – provided it’s safe to do so – given that studies show complications, particularly infections, are significantly increased in patients who rehab at a skilled nursing facility. “Each of our patients is evaluated in advance​ by a nurse navigator,” Dr. Star said. “Our primary concern is safety for the patient. We look at their homes, particularly stairs, and the availability of friends or relatives [to help at home]. We like to think of total joint arthroplasty like pregnancy, and everyone should have a coach.”

    Not every patient is on board with this approach at the beginning. “Managing expectations can be challenging, and we have had pushback from patients, families, and even primary care physicians,” Dr. Star said. “People have the idea that SNF rehab is equivalent to acute inpatient rehab and they remember when friends or relatives went to these types of facilities. But they do not see the complications that occur in SNF. It is all about education for the patient, their families, and the local community of physicians. And it remains a work in progress.”

    One of the most important messages from this study, Dr. Star said, “is that we must do what is best for our patients. Clearly, the nursing home is not the best place for the patient. Moreover, studies have been completed recently showing that it is safe [for joint replacement patients] to go home. Others have also shown that outpatient PT is much better than home PT.  “The take-home message is that these are not sick patients, but rather healthy patients with a bad joint. The healthiest alternative is for them to resume their lives ASAP.”


    Star AM, Vannello C, Austin M, Parvizi J, Janiec DA. Demand Matching Total Joint Replacement Patients Results in Reduction of Post-Discharge Costs (Paper 028). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.


    Ms. Vannello and Mr. Janiec have no disclosures for this study. Dr. Star has disclosed that he is a paid presenter for and receives research support from DePuy Synthes, that he is an employee of and has stock or stock options in Johnson & Johnson, that he has stock or stock options in Radlink, and that he is a paid consultant for Stryker. Dr. Austin has disclosed that he is a paid consultant for Corin USA, Link Orthopaedics, and Stryker and that he receives royalties and research from and is a paid consultant for Zimmer Biomet. Dr. Parvizi has disclosed that he has stock or stock options in Alphaeon, Ceribell, Cross Current Business Intelligence, Hip Innovation Technology, Intellijoint, Invisible Sentinel, Joint Purification Systems, MDValuate, MedAp, MicroGenDx, Parvizi Surgical Innovations, Physician Recommended Nutriceuticals, and PRN-Veterinary; that he is a paid consultant for CeramTec, ConvaTec, Ethicon, Heron, Tenor, TissueGene, and Zimmer Biomet; and that he receives royalties from, is a paid consultant to, and has stock or stock options in Corentec.