Becker's Spine Review

18 SPINE SURGEONS Spine bundled payments – 12 things to know By Laura Dyrda H ere are 12 key trends and findings on bundled payments in spine surgery as well as thoughts from four surgeons who believe bundling will become more prevalent in the future. 1. At the Association for Collaborative Spine Research during ISASS17 meeting, Philadelphia-based Rothman Institute President Alexander Vaccaro, MD, gave a presentation about his organization's efforts to implement bundled payments. SpineUniverse published coverage of the presentation. Key takeaways from Dr. Vaccaro's presentation include: • Identify costs for all individuals who have contact with the pa- tient or case from preoperative through the postoperative period to determine costs. • Physicians can determine controllable expenses and identify un- necessary costs, including imaging overuse. • Conduct a risk assessment for each patient to determine whether the inpatient or outpatient setting is the most appropriate for care. • Understand how the complexity of each case can influence as- sociated costs. • Negotiate reimbursement for episodes of care with the patient characteristics in mind. • Discharge patients based on their condition instead of maxi- mizing insurance coverage benefits, especially for postoperative rehabilitation. "A patient-facing compensation model would reimburse the same amount for the same service and not backload support payments for general — oen unneeded — facility resources into procedure reim- bursement," said Dr. Vaccaro during the presentation. "Be aware the differentials are becoming glaringly obvious to payers and the land- scape is changing. Expect a narrowing of these margins as payers get better control of their data." 2. UnitedHealthcare reported its value-based care program for spine surgeries were associated with 10 percent reduced readmissions and 3.4 percent fewer complications. e bundled payments for total joint replacement and spine bundles was almost $18 million. e payer re- ported its bundled payment solution reduced hospital readmissions for spine surgery by 10 percent and complications by 3.4 percent. Furthermore, UnitedHealthcare reported the average lumbar spinal fusion performed through its bundled payment program at a center of excellence was $65,800, compared to the national average of $80,000; discectomies were $24,550 through the bundled program, compared to $38,000 as the national average. 3. Humana expanded its Humana Medicare Advantage bundled payment program to include spinal fusion for four practices: Fort Wayne (Ind.) Orthopedics, Fort Wayne-based Ortho NorthEast, Cincinnati-based Mayfield Brain & Spine and OrthoVirginia with locations in Lynchburg, Richmond and northern Virginia. e payer has had a total joint bundle since 2016, which now has programs in 19 states at 60 practices. 4. Hospitals with spine bundled payments cite increased volume from large employers, including Walmart and Lowes, as well as third-party administrators was the biggest motivation for creating bundles, ac- cording to "A Survey of Innovative Reimbursement Models in Spine Care," published in a 2016 edition of Spine. In March 2019, Geisinger and Walmart teamed up to pen an article for the Harvard Business Review, detailing the program's success and out- comes. Around 2,300 Walmart employees underwent spine surgery or evaluation at a center of excellence from 2015 to 2018; 46 percent underwent surgery. e employees who underwent care at a center of excellence reported 0.4 days shorter lengths of stay at the hospital and 8 percent lower cost of care. e cost for COE patients was $32,177 on average, compared to $29,770 for non-COE patients. e article also reported 0.6 percent of the COE patients were dis- charged to a skilled nursing facility, compared to 2.9 percent of the non-COE patients. 5. An analysis of spine bundled payments published in the March 2019 issue of World Neurosurgery found hospitals are the primary re- cipient of bundled spine reimbursement, receiving 59.7 percent to 77 percent of the reimbursement. Surgeons typically receive 12.8 percent to 14 percent of the reimbursement while post-acute care rehabilita- tion receives 3.5 percent to 7.3 percent of the reimbursement. e average hospitalization index was $32,467 but could range from $11,880 to $107,642 and readmission could increase the 90-day pay- ment by 50 percent to 200 percent for patients undergoing uncompli- cated fusions. 6. e Bundled Payment for Care Improvement program has covered lumbar fusions for Medicare beneficiaries undergoing surgery at se- lect hospitals. Initiated in January 2013, the voluntary program covers 90-day episodes of care. A May 2018 study published in Spine exam- ines 89,605 Medicare beneficiaries who underwent lumbar fusions, with 7 percent coming from risk-bearing hospitals and 36 percent seen by a preparatory hospital. e study authors found procedure volume at risk-bearing hospitals in- creased slightly compared to non-participants, and the 90-day episodes did not reduce the cost of care. e bundled payment group also had a 2.7 percent increase in readmissions and 30.6 percent increase in repeat surgery rate. 7. A 2017 study by Sullivan et al., published in the Current Review of Musculoskeletal Medicine, found spine bundled payments worked better than the total joint bundles because they have the potential to be more cost-effective. Aer analyzing Medicare data for spinal fusion over a 10-year period, study authors found spinal fusion increased at a higher rate than total joint replacements and hospital charges were up 3.3-fold, hitting $33.9 billion in 2008. An analysis of one- and two-level ACDFs over seven years showed complications accounted for 0.7 percent of the 90-day reimbursement fund, and just 3.1 percent of reimbursements went to physical therapy, skilled nursing facilities and home health services. e 90-day bun- dled reimbursement hit $15,417 on average. "Bundled payments may also affect the location of and disposition following the procedure," concluded study authors. "A shi in case volume will continue towards ambulatory surgical centers. Early data suggests that, with the correct indications and patient population, de- creases in cost, morbidity and reoperation are observed."

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