Private payer bundled payment model may lead to cost savings for lumbar fusion
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Key takeaways:
- Discharge to acute inpatient rehabilitation and skilled nursing facilities decreased with a private payer bundled payment model for lumbar fusion.
- Readmissions also decreased in a private bundled payment model.
Results showed orthopedic practices may successfully implement nongovernmental bundled payment models for lumbar spinal fusion, with cost savings similar to those of the Bundled Payments for Care Improvement-Advanced Initiative.
“While systems may experience early losses, this should prompt increased focus on areas of potential cost-saving, utilizing various strategies to optimize target pricing and dedicate teams to optimize and negotiate with insurers,” the authors wrote. “Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties.”
Researchers retrospectively collected demographics, surgical characteristics and outcomes among patients who underwent lumbar fusion between Oct. 1, 2018, and Dec. 31, 2020, from a single commercial retrospective bundled payment model, grouped by calendar year. For a historical cohort, researchers collected data on Medicare patients who underwent spinal fusion from Oct. 1, 2018, to Dec. 31, 2018, during participation in the Bundled Payments for Care Improvement-Advanced (BPCI-A) Initiative. Researchers categorized discharge disposition as discharge home, home with health aid, skilled nursing facility or acute inpatient rehabilitation, and performed stepwise multivariate linear regression to measure independent predictors of net deficit.
Although year 1 in the single commercial retrospective bundle had the lowest net surplus, results showed this did not differ between the final year in BPCI-A and subsequent years in private payer bundles. Compared with BPCI, researchers found a significant decrease in acute inpatient rehabilitation and skilled nursing facility discharges in all private payer bundle years. Readmissions decreased from 10.7% in BPCI-A to 4.4% and 4.5% in years 2 and 3 of private payer bundles, respectively, according to researchers. Results showed an independent association between being in year 2 or year 3 of a single commercial retrospective bundle with a net surplus compared with year 1. Length of stay in days, readmission for any reason and discharge to acute inpatient rehabilitation or skilled nursing facility were associated with a net deficit, researchers found.
“Future studies are needed to create tools to risk-stratify patients and identify factors that preclude optimum cost savings for spinal fusion procedures,” the authors wrote.
Perspective
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James S. Harrop, MD, MSHQS, FACS
As a neurosurgeon working in public quaternary care hospital, I view the bundled payment model for lumbar spinal fusion as not the ideal solution. Firstly, present literature alone does not define the most optimal treatment algorithms for who and when a lumbar fusion should be implemented. Without these clear guidelines, there is an inability to optimize patient outcomes and maximize quality metrics. In addition, when for-profit groups define algorithms to maximize profits, they target the healthiest populations to have lowest adverse event rates. Hence, is it truly better care or maximizing profits by focusing on the lowest-risk population? The result is a higher concentration of sicker patients in the general population. The result is only cost shifting, not better care. Lastly, for those wishing to pursue a bundled payment, you should beware that although the incidence of catastrophic neurologic injury or adverse events is low, it is not zero. Therefore, you may lose any margin of financial profit quickly and this can result in complete financial burden. In many ways, you are gambling on not being unlucky.
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