Methods towards better care: An opinionated take on NEJM highlights for January 2019

The bundle

Unlike many other CMMI experiments, the Comprehensive Care for Joint Replacement (CJR) program was a true randomized control trial in that participation was mandatory in a selection of metropolitan areas and not allowed anywhere else, which allows for an analysis untainted by self-selection bias. In brief the question to be answered was does a 90-day bundled payment for a joint replacement (knee/hip) get better value (improved care and/or lower costs) than the traditional FFS approach? A differences of differences analysis comparing the bundled vs. control arms before and after the intervention finds that the most significant divergence between the two arms is the post-acute care management. This makes sense because as a procedure, joint replacement is pretty much standard, so that the main degree of freedom is what to do with the patient after it is done. What happened in the bundle arm is a marked decrease in the use of skilled nursing facilities and in-patient rehab and more patients using home health (but for fewer visits). Overall, this translated into a saving of $800 per patient (-3%), a substantial achievement in a couple years. This had no adverse effect on outcomes (readmissions, ED visits) which were, if anything better in the bundle arm than in the control. Recently though, the CJR stopped being mandatory, and only a minority of participants are continuing in this system. Given the shift of joint replacement to specialized ambulatory surgical centers, it is not clear that this model can work as implemented in CJR, but it does reaffirm something that we have all been too slow to discover; it’s the post-acute care stupid!

Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement (subscriber access)


The mystery shopper

Chefs at fancy restaurants live in fear of the Michelin man (or woman), that undercover professional diner who comes in unheralded and can make or break their business. Unfortunately, this is simply not done in medicine (although there are some exceptions such as this particularly edifying one). Here, an experienced doc takes his wife who has an upper respiratory infection to an urgent care clinic to get a chest x-ray to rule-out pneumonia. What ensues is a commentary on commercially savvy, friendly, totally incompetent care. One has to read it for oneself to appreciate the cantankerous style of a wise old doc, but I cannot resist a brief quotation:

‘Usually, Janice goes along with my undercover act, my preference not to reveal to her physicians that I’m a physician myself. It’s been educational: the dermatologists who insist on Mohs surgery to remove small superficial basal cells; the ophthalmologist who needed “cardiac clearance” before doing a simple office procedure; the podiatrist who wouldn’t treat plantar fasciitis without an MRI.’

I had a similar experience a few years ago when an urgent care clinic tried to discharge a household member on ibuprofen when I had noticed a lack of air movement in their left lung base. After arguing with the doc (who was board certified in emergency medicine no less!) an x-ray was obtained that showed a left lower lobe infiltrate.   There is a business concept out there, the Michelin guide for primary care – I’d use it.  The Spy Who Came In with a Cold (subscriber access)


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.

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