There are more than 400,000 Medicare beneficiaries who receive total joint replacements every year and costs for these procedures are increasing. Initiatives such as the Comprehensive Care for Joint Replacement program attempt to control costs through bundled payments on a 90-day episode of care.
An article published in the Journal of Bone and Joint Surgery examines the ethics of gainsharing in total joint arthroplasty as hospitals and physicians align to improve the quality and lower the cost of total joint replacements.
"Gainsharing is not a new concept in orthopedic surgery, but its inclusion in CJR is its most impactful implementation. However, there are ethical concerns that arise when instituting a program of incentivized financial partnerships between surgeons and hospitals," according to the article.
The CJR bundled payment program began for hospitals in 67 regions across the United States in April 2016 and included voluntary gainsharing arrangements between hospitals and collaborators, some of which were physicians. Here are a few of the potential ethical issues physicians face in the gainsharing model:
1. Physicians may change decision-making about patient care when financial incentives are involved, whether they do it consciously or unconsciously.
2. Since the device cost is among the most expensive aspects of surgery, the hospital and surgeon attempt to negotiate with device manufacturers on better pricing. If device companies can't meet the desired price point, surgeons may decide to switch devices and use an implant system they're less comfortable with.
3. Physicians could face malpractice liabilities if they use less expensive devices that lead to patient harm.
4. Organizations that implement gainsharing must ensure quality doesn't slip. It's incumbent on the providers to make sure there is clinical equivalency between two resources with different costs and ensure any gainsharing arrangements are compliant with the DOJ and OIG regulations.
5. Providers must weigh whether increased costs upfront could lead to lower costs in post-surgical care and how short-term costs can impact long-term savings in terms of the technology survivorship and clinical complications. A more expensive implant that lasts longer and leads to fewer complications could save on the back end.
6. The patient's role in decision-making can also impact gainsharing arrangements. Current gainsharing models don't take patient preference into account.
7. Gainsharing models incentivize physicians to minimize risk, and those who are at a higher risk for complications or may need additional post-surgical care are in danger of not receiving the care they need.
8. Orthopedic device manufacturers are concerned gainsharing measures could stifle innovation as the companies aren't incentivized to invest in research and development. The gainsharing model may also make it more difficult for small companies and start-ups to break into the market with new technology.
"The important concerns discussed in this review must be addressed by implementation of the proper safeguards, including monitoring by legal oversight bodies such as the OIG and DOJ," concluded the article's authors. "Surgeons must also ensure that clinical decisions made for short-term gain do not have adverse long-term consequences."