Becker's Spine Review

10 SPINE SURGEONS 9 key thoughts on bundled payments in spine surgery By Alan Condon N ine insights on bundled payments in spine, including CMS changes in 2021: 1. While bundled payments have found some success in total joint replacement, many spine surgeons are not sold on the idea due to the wide variation of surgeries, approaches and levels that may be operated on in any given diagnosis, as well as the cost differences based on in- and outpatient settings. However, many stakeholders — hospitals, consumers, payers and employers — have embraced bundles. 2. While the purpose of bundled payment pro- grams is to cut costs, many physicians are con- cerned about the effects on quality and safety. An analysis of CMS' Bundled Payments for Care Improvement initiative found no change in length of stay for spinal fusion and an in- crease in both 90-day emergency room use and 90-day readmission rate, according to the American Academy of Orthopaedic Surgeons. Additionally, there was an increased rate of subsequent surgery at participating hospitals within the 90-day bundle period. 3. As healthcare in the U.S. continues its push from a fee-for-service model toward val- ue-based care, physicians are expected more than ever to demonstrate the benefit of their interventions and accurately predict costs, ac- cording to University of California San Fran- cisco neurosurgeon Christopher Ames, MD. "ere are currently no validated predictive models of improvement that could be used to generate reliable bundle payment options for complex spine surgery," Dr. Ames said. How- ever, UCSF, in collaboration with the Inter- national Spine Study Group, is applying ac- curate predictive models deemed pivotal "to prevent incentives for providers to withhold care in value-based care models." 4. A study published in e Spine Journal cal- culated 90-day costs for all lumbar fusions to be $31,716 ± $18,124, with individual 90-day payments being $54,607 ± $30,643 in DRG-459 — spinal fusion except cervical with major comorbidity or complication — and $30,338 ± $16,074 in DRG-460 — spinal fusion except cervical without major comor- bidity or complication. Researchers called on policymakers to account for individual patient, state and procedure variation seen within diagnosis-related groups to stop the formation of financial disincentives in car- ing for sicker patients and performing more complex fusions. 5. A well-rounded bundled payment model for spine could be cemented within the next eight to 10 years, according to David Janiec, a financial services executive with expertise in value-based care and alternative payment models. "Early activity in bundled programs demonstrates the development of increased use of evidenced-based medicine, a better understanding of costs, improvements in care coordination and higher quality pa- tient care, " Mr. Janiec said. "It is extremely important not only to participate in these value-based models for educational and fi- nancial benefit, currently, but also to look with a critical eye to ensure a sustainable final model evolves." 6. CMS made several changes to the BPCI Advanced program for 2021, the most sig- nificant of which is that participants are no longer able to select individual episode types, such as lower extremity, upper extremity or spinal fusion. 7. Last year, UnitedHealthcare expanded BPCI Bundled Payments to include Medicare Advantage beneficiaries. e UnitedHealth- care Care Bundles program offers bundled payments for noncervical spinal fusions. In 2019, Humana began offering Humana Medi- care Advantage members access to bundled payments for spinal fusion. 8. Two condition-specific bundle pay- ment programs recently emerged for spine surgery as well as joint replacement and bariatric surgery, according to the Ameri- can Journal of Managed Care. The Pacific Business Group on Health/Health Design Plus Employers Centers of Excellence Net- work created a direct-to-employer program where condition-specific bundle payment programs are created for high-volume, high-quality centers. Largely through re- ductions in surgical rates, the program de- creased costs by about $1.2 million for joint replacement and spine surgery. 9. A study on bundled payments for lumbar spinal fusions found increased case com- plexity was responsible for rising costs rel- ative to the negotiated baseline target price. Researchers analyzed two-year data of one institution participating in the BPCI pro- gram and determined that the value-based model "may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and tech- nologies." n Neurosurgeon pay hits $645K & 3 more notes By Laura Dyrda N eurosurgeons have the highest median salary among specialties sur- veyed in the "Physician Compensation Report 2020" from Physicians Thrive, a financial planning company. The report authors compiled data from the U.S. Bureau of Labor Statistics, Dox- imity, Merritt Hawkins, Medscape and Salary.com to develop the report. Four notes on neurosurgeon pay: 1. Neurosurgeons reported median salary of $645,000 and ranked No. 1 as the highest compensated specialty among those surveyed for the report. 2. Neurosurgeons in the Midwest reported the highest median salary of any specialty at $760,000 per year. 3. The lowest average compensation for neurosurgeons was in the eastern re- gion of the U.S., where neurosurgeons earned $600,000 on average. 4. The average signing bonus for neurosurgeons was $47,500. n

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