New Jersey's Experience

CHART logo

CHART analyzed data from 2015 through 2018 to identify changes in discharge status for patients in hospitals mandated by CMS to participate in the CJR program, in hospitals that participated in the Bundled Payment for Care Improvement (BPCI) “Classic” program, and in hospitals that participated in neither of these bundling initiatives. BPCI “Classic” was CMS’ first voluntary bundling initiative carried out from 2013 through 2016 under the statutory authority of the Affordable Care Act which established the Center for Medicare and Medicaid Innovation (CMMI). Hospitals, physician group practices and post-acute providers were able to choose from four different models under BPCI to engage in bundled payments for up to 48 different clinical episodes.

A comparison of the average length of stay (LOS) in 2018 for hip and knee replacement patients across the three groups revealed the following:

  • For CJR hospitals, the LOS was 2.6 days
  • For BPCI (non-CJR) hospitals, 1.7 days
  • For hospitals in neither program, the average LOS was 2.4 days.

Over the three-year period CHART studied, all three hospital groups’ overall LOS trended downward for these patients. CHART also reviewed LOS trends by fracture/non-fracture status and found the following:

  • In 2018, LOS for patients with fractures in CJR hospitals was 5.5 days, while the non-fracture patients had a LOS of 2.2 days
  • In BPCI-only hospitals, the LOS was 5.3 days and 1.5 days, respectively
  • And in non-CJR/non-BPCI hospitals, the LOS was, 5.4 days and 1.9 days, respectively.

Since BPCI began two years earlier than CJR, it stands to reason that the BPCI hospitals’ have had more time to develop strategies to improve LOS for both types of patients.

Nationally, for CJR hospitals the average acute care hospital LOS decreased from 3.4 days at baseline (2015) to 2.9 days in 2018; for non-CJR hospitals, LOS decreased from 3.3 days to 2.8 days. In summary, New Jersey’s CJR hospitals’ LOS started slightly lower than the national average in 2015 and continued to be better than the national average in 2018.

As the graphs below illustrate, for all three groups of New Jersey hospitals (CJR, BPCI or neither), discharge to inpatient rehabilitation facilities (IRF) has decreased over the period. Nationally, according to the evaluation conducted by the Lewin Group,3 there was a 2.0 percentage point relative decrease in the proportion of patients who were discharged immediately following their acute care stay to an IRF.

Discharge to skilled nursing facilities (SNFs) has trended downward for New Jersey CJR hospitals and for hospitals that are in neither CJR or BPCI. Interestingly, hospitals that participated only in BPCI saw an upward trend in discharge to SNF. However, these hospitals started with a lower percentage of their hip and knee replacement patients being discharged to SNF at the start of the period at 10 percent, compared with the CJR hospitals at 45 percent and the non-CJR, non-BPCI hospitals at 33 percent.

These findings stimulated further review of the patients in the DRGs in question to see if the volume of patients with a hip replacement caused by a fracture could be related to some of the trends identified. Approximately 10-13 percent of patients in CJR hospitals and hospitals without CJR or BPCI had a fracture identified. However, non-CJR hospitals that participated in BPCI had 5 to 6 percent of patients with a fracture identified – a much lower rate. However, there was no real difference in discharge status in New Jersey related to a fracture being the cause of the joint replacement. This is different from what Lewin observed across the nation, in which SNF care was substituted for IRF care for CJR patients in fracture episodes.3

Significant variation exists in discharge to home health. Again, New Jersey’s CJR hospitals and hospitals in neither CJR nor BPCI discharged more patients to home health over the period. However, there is a sharp downward trend in discharges to home health for BPCI-only hospitals. According to the national evaluation conducted by Lewin3, the proportion of CJR patients initially discharged to a home health agency increased from 42.6 percent to 49.1 percent, compared with a change from 39.9 percent to 42 percent for non-CJR hospitals.

Discharge to home with only self-care also showed interesting trends by hospital type. CJR hospitals have steadily had the lowest discharge percentage (15-18 percent) in this category. Hospitals without CJR or BPCI have been steadily increasing the percentage of patients discharged to self-care – from 28 to 46 percent between 2015 and 2018. Non-CJR hospitals that participated in BPCI trended sharply upward in this category, going from 29 percent in 2015 to 60 percent in 2018. This significant upward trend could be related to the relative lower level of complexity of the patient population in non-CJR hospitals that participated in BPCI as demonstrated by the lower percentage of hip and knee replacement patients that had a fracture identified as the cause.

Additional Findings

With respect to readmissions, in 2017 and 2018 the CJR-only hospitals statewide had a readmission rate of 4 percent for hip and knee replacement patients. Hospitals that were neither in CJR or BPCI had readmissions rates of 4.75 percent in 2017 and 5.6 percent in 2018. Further analysis is necessary to determine whether the increase in readmissions in these hospitals could be related to the BPCI hospitals’ increase in discharge to skilled nursing facilities, as noted earlier.

By contrast, hospitals that were only in BPCI had readmission rates of 1.83 percent in 2017 and 2.54 percent in 2018. This again could be related to the relative lower level of complexity of the non-CJR hospitals that participated in BPCI, as mentioned previously.

CHART also analyzed whether there are racial disparities among Medicare beneficiaries who are undergoing hip or knee replacement procedures in New Jersey and found that blacks and Asians are less likely to undergo these procedures as compared to the percentage of the population they make up in the counties CJR hospitals serve. In the counties served by CJR hospitals, blacks make up 8.1 percent of these patients compared to 12 percent of the counties’ population, while Asians make up 3.3 percent of the patients compared to 10 percent of the population. By contrast, whites constituted 82 percent of patients, but made up 75.4 percent of the population in the counties.

  1. Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement, New England Journal of Medicine, Michael L. Barnett, M.D., Andrew Wilcock, Ph.D., J. Michael McWilliams, M.D., Ph.D., Arnold M. Epstein, M.D., Karen E. Joynt Maddox, M.D., M.P.H., E. John Orav, Ph.D., David Grabowski, Ph.D., and Ateev Mehrotra, M.D., M.P.H., Jan. 2, 2019.
  2. Performance of Safety-Net Hospitals in Year 1 of the Comprehensive Care for Joint Replacement Model, Health Affairs, Caroline P. Thirukumaran, Laurent G. Glance, Xueya Cai, Rishi Balkissoon, Addisu Mesfin, and Yue Li, February 2019, 38:2.
  3. CMS Comprehensive Care for Joint Replacement Model: Performance Year 1 Evaluation Report, The Lewin Group, August 2018,