Early Effects of Medicare's Bundled Payment for Care Improvement Program for Lumbar Fusion

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

BACKGROUND

Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES

We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN

With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS

A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES

Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.

RESULTS

Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS

After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Risk stratification of patients undergoing outpatient lumbar decompression surgery

BACKGROUND CONTEXT

Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers.

PURPOSE

To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay.

STUDY DESIGN/SETTING

Retrospective single-institution cohort.

PATIENT SAMPLE

A total of 1656 patients undergoing primary lumbar decompression.

OUTCOME MEASURES

Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay.

METHODS

Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified.

RESULTS

A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model

STUDY DESIGN/SETTING

Retrospective.

OBJECTIVE

To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease.

SUMMARY OF BACKGROUND DATA

Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery.

METHODS

The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups.

RESULTS

A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012].

CONCLUSIONS

Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

Trends in Reimbursement and Approach Selection for Lumbar Arthrodesis

BACKGROUND

Changes in reimbursement policies have been demonstrated to correlate with clinical practice.

OBJECTIVE

To investigate trends in physician reimbursement for anterior, posterior, and combined anterior/posterior (AP) lumbar arthrodesis and relative utilization of AP.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Project registry for anterior, posterior, and AP lumbar arthrodeses during 2010 and 2020. Work relative value units per operative hour (wRVUs/h) were calculated for each procedure. Trends in reimbursement and utilization of the AP approach were assessed with linear regression. Subgroup analyses of age and underlying pathology of AP arthrodesis were also performed.

RESULTS

During 2010 and 2020, AP arthrodesis was associated with significantly higher average wRVUs/h compared with anterior and posterior arthrodesis (AP = 17.4, anterior = 12.4, posterior = 14.5). The AP approach had a significant yearly increase in wRVUs/h (coefficient = 0.48, P = .042), contrary to anterior (coefficient = -0.01, P = .308) and posterior (coefficient = -0.13, P = .006) approaches. Utilization of AP approaches over all arthrodeses increased from 7.5% in 2010 to 15.3% in 2020 (yearly average increase 0.79%, P < .001). AP fusions increased significantly among both degenerative and deformity cases (coefficients 0.88 and 1.43, respectively). The mean age of patients undergoing AP arthrodesis increased by almost 10 years from 2010 to 2020. Rates of major 30-day complications were 2.7%, 3.1%, and 3.5% for AP, anterior, and posterior arthrodesis, respectively.

CONCLUSION

AP lumbar arthrodesis was associated with higher and increasing reimbursement (wRVUs/h) during the period 2010 to 2020. Reimbursement for anterior arthrodesis was relatively stable, while reimbursement for posterior arthrodesis decreased. The utilization of the combined AP approach relative to the other approaches increased significantly during the period of interest.

Bundled Payments for Care Improvement Efficacy Across 3 Common Operations

OBJECTIVE

The aim of this study was to evaluate associations between hospital participation in Bundled Payments for Care Improvement (BPCI) and 30-day total episode and post-acute care spending for lower extremity joint replacement (LEJR), coronary artery bypass graft (CABG), and colec-tomy.

SUMMARY BACKGROUND DATA

BPCI has been shown to reduce spending for LEJR episodes largely from reductions in post-acute care. However, BPCI efficacy in other common elective procedures, including CABG and colec-tomy, remains unclear. It is also unknown whether post-acute care spending reductions drive total spending reductions outside of LEJR.

METHODS

Retrospective cohort study using 100% Medicare claims data to identify BPCI (312 total) and non-BPCI (1,977 total) acute care hospitals from January 1, 2010 to November 30, 2016 with Medicare-enrolled patient discharges for at least one of the following BPCI episodes: LEJR (454,369 episodes), CABG (107,307 episodes), or colectomy (73,717 episodes). Along with difference-in-differences (DiD) analysis, we constructed generalized synthetic controls in the presence of nonparallel trends to estimate associations between BPCI participation and 30-day total and post-acute care spending.

RESULTS

DiD estimates indicated reduced spending for LEJR (-$541.6 [95% confidence interval (CI): -718.0 to -365.3]) and colectomy (-$582.1 [95% CI: -927.3 to -236.8]) but not CABG (-$268.9 [95% CI: -831.5 to 293.7]). Generalized synthetic control estimates indicated reduced spending for LEJR (-$795.3 [95% CI: -10,22.1 to -582.2]) but not colectomy (-$251.3 [95% CI: -997.9 to 335.2]) or CABG (-$257.8 [95% CI: -10,24.6 to 414.8]).Post-acute care comprised 42.6% of LEJR spending reductions and 53.0% of colectomy spending reductions.

CONCLUSIONS

BPCI participation was associated with significant spending reductions for LEJR and colectomy but not CABG. We conclude that BPCI has episode-dependent efficacy, largely determined by post-acute care.

Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models.

BACKGROUND

The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care.

MATERIALS AND METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean.

RESULTS

There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86).

CONCLUSIONS

Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.

Is Discretionary Care Associated with Safety Among Medicare Beneficiaries Undergoing Spine Surgery?

BACKGROUND

Spine surgery and its corresponding costs have increased in recent years and are variable across geographic regions. Discretionary care is the component of spending variation that is independent of illness severity, age, and regional pricing. It is unknown whether greater discretionary care is associated with improved safety for patients undergoing spine surgery, as we would expect from value-based health care.

METHODS

We conducted an analysis of 5 spine surgery cohorts based on Medicare claims from 2013 to 2017. Patients were grouped into quintiles based on the Dartmouth Atlas End-of-Life Inpatient Care Index (EOL), reflecting regional spending variation attributed to discretionary care. Multivariable regression examined the association between discretionary care and safety measures while controlling for age, sex, race, comorbidity, and hospital features.

RESULTS

We observed a threefold to fourfold variation in 90-day episode-of-care cost across regions, depending on the cohort. Spine-specific spending was correlated with EOL quintile, confirming that spending variation is due more to discretionary care than it is to pricing, age, or illness severity. Greater spending across EOL quintiles was not associated with improved safety, and, in fact, was associated with poorer safety in some cohorts. For example, all-cause readmission was greater in the high-spending EOL quintile relative to the low-spending EOL quintile among the "fusion, except cervical" cohort (14.2% vs. 13.1%; OR = 1.10; 95% CI = 1.05 to 1.20), the "complex fusion" cohort (28.0% vs. 25.4%; OR = 1.15; 95% CI = 1.01 to 1.30), and the "cervical fusion" cohort (15.0% vs. 13.6%; OR = 1.12; 95% CI = 1.05 to 1.20).

CONCLUSIONS

Wide variation in spending was not explained by differences in illness severity, age, or pricing, and increased discretionary care did not enhance safety. These findings point to inefficient use of health-care resources, a potential focus of reform.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices

OBJECTIVE

Musculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.

DESIGN

Cross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.

SETTING

Primary and secondary care in 2190 physician practices.

PARTICIPANTS

39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.

RESULTS

Total annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.

CONCLUSIONS

Practice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

Osseodensification drilling vs conventional manual instrumentation technique for posterior lumbar fixation: Ex-vivo mechanical and histomorphological analysis in an ovine model

Lumbar fusion is a procedure associated with several indications, but screw failure remains a major complication, with an incidence ranging 10% to 50%. Several solutions have been proposed, ranging from more efficient screw geometry to enhance bone quality, conversely, drilling instrumentation have not been thoroughly explored. The conventional instrumentation (regular [R]) techniques render the bony spicules excavated impractical, while additive techniques (osseodensification [OD]) compact them against the osteotomy walls and predispose them as nucleating surfaces/sites for new bone. This work presents a case-controlled split model for in vivo/ex vivo comparison of R vs OD osteotomy instrumentation in posterior lumbar fixation in an ovine model to determine feasibility and potential advantages of the OD drilling technique in terms of mechanical and histomorphology outcomes. Eight pedicle screws measuring 4.5 mm × 45 mm were installed in each lumbar spine of eight adult sheep (four per side). The left side underwent R instrumentation, while the right underwent OD drilling. The animals were killed at 6- and 12-week and the vertebrae removed. Pullout strength and non-decalcified histologic analysis were performed. Significant mechanical stability differences were observed between OD and R groups at 6- (387 N vs 292 N) and 12-week (312 N vs 212 N) time points. Morphometric analysis did not detect significant differences in bone area fraction occupancy between R and OD groups, while it is to note that OD showed increased presence of bone spiculae. Mechanical pullout testing demonstrated that OD drilling provided higher degrees of implant anchoring as a function of time, whereas a significant reduction was observed for the R group.

Bundled Payment Models in Spine Surgery

STUDY DESIGN

The following is a narrative discussion of bundled payments in spine surgery.

OBJECTIVE

The cost of healthcare in the United States has continued to increase. To lower the cost of healthcare, reimbursement models are being investigated as potential cost saving interventions by driving incentives and quality improvement in fields such a spine surgery.

METHODS

Narrative overview of literature pertaining to bundled payments in spine surgery synthesizing findings from computerized databases and authoritative texts.

RESULTS

Spine surgery is challenging to define payment modes because of high cost variability and surgical decision-making nuances. While implementing bundled care payments in spine surgery, it is important to understand concepts such as value-based purchasing, episodes of care, prospective versus retrospective payment models, one versus two-sided risk, risk adjustment, and outlier protection. Strategies for implementation underscore the importance of risk stratification and modeling, adoption of evidence based clinical pathways, and data collection and dissemination. While bundled care models have been successfully implemented, challenges facing institutions adopting bundled care payment models include financial stressors during adoption of the model, distribution of risks, incentivization of treating only low risk patients, and nuanced variation in procedures leading to variation in costs.

CONCLUSION

An alternative for fee for service payments, bundled care payments may lead to higher cost savings and surgeon accountability in a patient's care.

Higher complication rates after management of lower extremity fractures in lower socioeconomic classes: Are risk adjustment models necessary?

Introduction

Alternative payment models, such as bundled payments, have been proposed to control rising costs in orthopaedic trauma surgery. Without risk adjustment models, concerns exist about the financial burden incurred by so called “safety-net hospitals” that serve patients of lower socioeconomic status. The purpose of this study was to determine whether lower socioeconomic status was associated with increased complications and subsequently higher resource utilization following surgical treatment of high-energy lower extremity fractures.

Methods

The National Inpatient Sample database was queried for patients who underwent surgical fixation of the femur and tibia between 2005–2014. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay (LOS), complications, in-hospital mortality were compared between patients of top and bottom income quartiles. Multivariate logistic regression analysis was then performed to identify factors independently associated with complications, mortality, and increased resource utilization.

Results

Patients with femur fracture in the bottom income quartile had longer length of stay (6.9 days vs 6.5 days, p < 0.001) and a higher mortality rate (1.9% vs 1.7%, p = 0.034). Patients with tibia fracture in the bottom income quartile had greater complication rates (7.3% vs 6.1%, p < 0.001), longer length of stay (5.3 days vs. 4.5 days, p < 0.001), and higher mortality (0.3% vs. 0.2%, p < 0.001).

Conclusions

Lower income status is associated with increased in-hospital mortality and longer length of stay in patients following lower extremity fractures. Risk adjustment models should consider the role of socioeconomic status in patient resource utilization to ensure continued access to orthopedic trauma care for all patients.

A Cost-Effectiveness Analysis of Smoking-Cessation Interventions Prior to Posterolateral Lumbar Fusion

BACKGROUND

Smoking cessation represents an opportunity to reduce both short and long-term effects of smoking on complications after lumbar fusion and smoking-related morbidity and mortality. However, the cost-effectiveness of smoking-cessation interventions prior to lumbar fusion is not fully known.

METHODS

We created a decision-analytic Markov model to evaluate the cost-effectiveness of 5 smoking-cessation strategies (behavioral counseling, nicotine replacement therapy [NRT], bupropion or varenicline monotherapy, and a combined intervention) prior to single-level, instrumented lumbar posterolateral fusion (PLF) from the health payer perspective. Probabilities, costs, and utilities were obtained from published sources. We calculated the costs and quality-adjusted life years (QALYs) associated with each strategy over multiple time horizons and accounted for uncertainty with probabilistic sensitivity analyses (PSAs) consisting of 10,000 second-order Monte Carlo simulations.

RESULTS

Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon. In the short term, behavioral counseling, NRT, varenicline monotherapy, and the combined intervention were also cost-saving, while bupropion monotherapy was more effective but more costly than usual care. The mean lifetime cost savings for behavioral counseling, NRT, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291 (standard deviation [SD], $868), $2,571 (SD, $479), $2,851 (SD, $830), $6,767 (SD, $1,604), and $34,923 (SD, $4,248), respectively. The minimum efficacy threshold (relative risk for smoking cessation) for lifetime cost savings varied from 1.01 (behavioral counseling) to 1.15 (varenicline monotherapy). A PSA revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.

CONCLUSIONS

Even brief smoking-cessation interventions yield large short-term and long-term cost savings. Smoking-cessation interventions prior to PLF can both reduce costs and improve patient outcomes as health payers/systems shift toward value-based reimbursement (e.g., bundled payments) or population health models.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Low Socioeconomic Status Is Associated With Increased Complication Rates: Are Risk Adjustment Models Necessary in Cervical Spine Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objective of this study was to determine whether lower socioeconomic status was associated with increased resource utilization following anterior discectomy and fusion (ACDF).

METHODS

The National Inpatient Sample database was queried for patients who underwent a primary, 1- to 2-level ACDF between 2005 and 2014. Trauma, malignancy, infection, and revision surgery were excluded. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay, complications, and hospital cost were compared between patients of top and bottom income quartiles.

RESULTS

A total of 69 844 cases were included. The bottom income quartile had a similar mean hospital stay (2.04 vs 1.77 days, P = .412), more complications (2.45% vs 1.77%, P < .001), and a higher mortality rate (0.18% vs 0.11%, P = .016). Multivariate analysis revealed bottom income quartile was an independent risk factor for complications (odds ratio = 1.135, confidence interval = 1.02-1.26). Interestingly, the bottom income quartile experienced lower mean hospital costs ($17 041 vs $17 958, P < .001).

CONCLUSION

Patients in the lowest income group experienced more complications even after adjusting for comorbidities. Therefore, risk adjustment models, including socioeconomic status, may be necessary to avoid potential problems with access to orthopedic spine care for this patient population.

Medicare's Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.

CONTEXT

Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

METHODS

We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.

FINDINGS

Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.

CONCLUSIONS

Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

Fellow Versus Resident: Graduate Medical Education and Patient Outcomes After Anterior Cervical Diskectomy and Fusion Surgery

INTRODUCTION

The effect of spine fellow versus orthopaedic surgery resident assistance on outcomes in anterior cervical diskectomy and fusion (ACDF) has not been well studied. The objective of this study was to determine differences in patient health-related outcomes based on the level of surgical trainees.

METHODS

Consecutive cases of ACDF (n = 407) were reviewed at a single high-volume institution between 2015 and 2017 and were separated into two groups based on whether they were fellow-assisted or resident-assisted. Demographic and clinical variables were recorded, and health-related quality of life was evaluated using the Short Form-12 (SF-12) survey. The SF-12, visual analog scale pain score, and neck disability index were compared between the two groups. Surgery level, surgical time, preoperative Charlson Comorbidity Index, estimated blood loss, equivalent morphine use, perioperative complications, and 30-day readmission were also recorded. Patient outcomes were compared using an unpaired t-test as well as multivariate linear regression, controlling for age, sex, body mass index, Charlson Comorbidity Index, presurgical visual analog scale, SF-12, and neck disability index. Results were reported with the 95% confidence interval.

RESULTS

Spine surgery fellows and orthopaedic surgery residents participated in 228 and 179 ACDF cases, respectively. No notable demographic differences between the two groups were found. A higher proportion of three or more level ACDF surgeries assisted by fellows versus residents was found. Estimated blood loss was greater in fellow-assisted ACDF cases. Both surgery time and total time in the room were also longer in the fellow-assisted ACDF group. No 30-day readmissions were found in either groups, and only one case of acute hemorrhagic anemia was found in the fellow-assisted group. Overall, postoperative complications were higher in the resident group; however, no difference with regard to intraoperative complications between groups was found.

DISCUSSION

This study shows that patient health-related outcomes are similar in ACDF cases that were fellow-assisted versus resident-assisted. However, fellow-assisted ACDF cases were associated with more blood loss and longer surgery time.

Utilization of Predictive Modeling to Determine Episode of Care Costs and to Accurately Identify Catastrophic Cost Nonwarranty Outlier Patients in Adult Spinal Deformity Surgery: A Step Toward Bundled Payments and Risk Sharing

STUDY DESIGN

Retrospective review of prospectively-collected, multicenter adult spinal deformity (ASD) database.

OBJECTIVE

The aim of this study was to evaluate the rate of patients who accrue catastrophic cost (CC) with ASD surgery utilizing direct, actual costs, and determine the feasibility of predicting these outliers.

SUMMARY OF BACKGROUND DATA

Cost outliers or surgeries resulting in CC are a major concern for ASD surgery as some question the sustainability of these surgical treatments.

METHODS

Generalized linear regression models were used to explain the determinants of direct costs. Regression tree and random forest models were used to predict which patients would have CC (>$100,000).

RESULTS

A total of 210 ASD patients were included (mean age of 59.3 years, 83% women). The mean index episode of care direct cost was $70,766 (SD = $24,422). By 90 days and 2 years following surgery, mean direct costs increased to $74,073 and $77,765, respectively. Within 90 days of the index surgery, 11 (5.2%) patients underwent 13 revisions procedures, and by 2 years, 26 (12.4%) patients had undergone 36 revision procedures. The CC threshold at the index surgery and 90-day and 2-year follow-up time points was exceeded by 11.9%, 14.8%, and 19.1% of patients, respectively. Top predictors of cost included number of levels fused, surgeon, surgical approach, interbody fusion (IBF), and length of hospital stay (LOS). At 90 days and 2 years, a total of 80.6% and 64.0% of variance in direct cost, respectively, was explained in the generalized linear regression models. Predictors of CC were number of fused levels, surgical approach, surgeon, IBF, and LOS.

CONCLUSION

The present study demonstrates that direct cost in ASD surgery can be accurately predicted. Collectively, these findings may not only prove useful for bundled care initiatives, but also may provide insight into means to reduce and better predict cost of ASD surgery outside of bundled payment plans.

LEVEL OF EVIDENCE

3.

Preoperative Maximization to Reduce Complications in Spinal Surgery

STUDY DESIGN

Invited narrative review.

OBJECTIVES

The aim of this review was to summarize current literature regarding risk factors that surgeons can optimize in the preoperative setting in the spinal surgery patient, in order to reduce complications and improve patient-reported outcomes.

METHODS

Review of the relevant literature by the authors.

RESULTS

Modifiable risk factors identified relative to the patient include obesity, malnutrition/nutrient deficiency, diabetes/hyperglycemia, preoperative anemia, vitamin D/DEXA (dual-energy radiograph absorptiometry), nicotine use/smoking, and opioid use/psychosocial factors.

CONCLUSION

By maximizing a patient's physiological and psychological status prior to elective spine surgery, we may move closer to achieving the goals of value-based care: improving patient-reported outcomes while decreasing the cost of care.

Are current DRG-based bundled payment models for lumbar fusions risk-adjusting adequately? An analysis of Medicare beneficiaries

BACKGROUND CONTEXT

Current bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture.

PURPOSE

We carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions.

STUDY DESIGN

Retrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5).

OUTCOME MEASURES

To understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460.

METHODS

The 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates.

RESULTS

A total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70-74 years: +$2,387, 75-79 years: +$3,389, 80-84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors-undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315).

CONCLUSIONS

Under the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1-3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.

Epidemiology and Socioeconomic Trends in Adult Spinal Deformity Care

Adult spinal deformity (ASD) has gained significant attention over the past decade with improvements in diagnostic tools, classification schemes, and surgical technique. The demographics of the aging population in the United States are undergoing a fundamental shift as medical care advances and life expectancy increases. The “baby boomers” represent the fastest growing demographic in the United States and by 2050, the number of individuals 65 yr and older is projected to reach 89 million, more than double its current size. Based on current prevalence estimates there are approximately 27.5 million elderly individuals with some form of spinal deformity, which will place a significant burden on our health care systems. Rates of surgery for ASD and case complexity are both increasing, with concomitant increase in the cost of deformity care. At the same time, patients are more medically complex with increasing number of comorbidities that result in increased surgical risk and complication profiles. This review aims to highlight recent trends in the epidemiology and socioeconomic patterns in surgery for ASD.

Simulating Episode-Based Bundled Payments for Cranial Neurosurgical Procedures

BACKGROUND

Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Payments for Care Improvement (BPCI) in order to improve care coordination and cost efficiency. BPCI has not yet been applied to cranial neurosurgical procedures.

OBJECTIVE

To determine projected values of episode-based bundled payments when applied to common cranial neurosurgical procedures using retrospective data from a large database.

METHODS

We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment payments for 4 groups of common cranial neurosurgical procedures.

RESULTS

We identified 15 276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-d bundle projected payments ranging from $ 58,200 for craniotomy for meningioma to $ 102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected payments for a 30-d bundle and 70.5% of projected payments for a 90-d bundle. Multivariable analysis showed that hospital readmission, discharge to postacute care facilities, venous-thrombo-embolism, medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle payments.

CONCLUSION

For the first time, to our knowledge, we project the values of episode-based bundled payments for common vascular and tumor cranial operations. As previously identified in orthopedic procedures, there is significant variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, postdischarge care significantly impacts total bundle payments in cranial neurosurgery.