Hospitals Did Not Increase Acute Occupational Therapy Provision Despite Positive Associations With Hospital Performance Under Medicare's Comprehensive Care for Joint Replacement Program

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) program rewards hospitals for reducing total Medicare spending. Despite the benefits of occupational therapy (OT) for patient outcomes and spending, little is known about how CJR affects hospital provision of acute occupational OT services.

Objective: Determine whether CJR changed acute OT provision and whether higher acute OT provision was associated with CJR rewards.

Design: Cohort study with randomization.

Setting: Hospitals.

Participants: Patients covered by Medicare who were discharged after major joint replacement surgery (n = 1,006,938) in 722 hospitals randomly selected for treatment under CJR and 859 hospitals in the control group, before (July 2014-June 2015) and after (April 2016-December 2018) CJR in the United States.

Outcomes and measures: National Medicare inpatient claims data were used to examine diagnoses and per-hospitalization acute OT provision (OT costs, patient receipt of OT, and OT share of hospitalization costs). CJR files were used to determine hospital rewards (CJR dollars per discharge).

Results: CJR did not affect acute OT provision in terms of per-hospitalization OT costs, patient receipt of OT, or OT share of total hospitalization costs. Each additional dollar of OT spent by hospitals was associated with an increase of $1.99 CJR reward dollars (95% confidence interval [0.82, 3.16]).

Conclusions and relevance: These results indicate that hospitals did not increase acute OT as part of their improvement strategy under CJR, despite the potential for acute OT to yield financial returns on investment. Plain-Language Summary: Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment program rewards hospitals for low Medicare spending from hospitalization through 90 days postdischarge. Although occupational therapy (OT) improves patient-centered care and reduces Medicare spending, it is unknown whether hospitals modified (or targeted) acute OT services when treating older patients who were hospitalized for major joint replacement surgery under CJR. We used national Medicare data to characterize the variation in hospital use of acute OT and to identify how CJR affected acute OT use by hospitals. We then examined whether acute OT use was associated with financial returns on investment by hospitals in CJR. We found that acute OT use did not change under CJR, even though higher OT use was correlated with larger financial rewards for CJR hospitals. Future research should focus on quantifying the value-added of OT on patient outcomes and Medicare spending.