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  • Misaligned Incentives for Lumbar Spine Surgery in the Bundled Payment for Care Initiative

    Final Number:

    Joseph E Tanenbaum BA; Dominic Pelle MD; Edward C. Benzel MD; Michael P. Steinmetz MD; Thomas Mroz

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Under the Bundled Payments for Care Initiative (BPCI), Medicare reimburses for lumbar fusion without adjusting for the patient’s underlying pathology. We compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle: patients with spondylolisthesis and patients with thoracolumbar fracture.

    Methods: With BPCI, hospitals are reimbursed for a lumbar fusion episode of care if patients are assigned diagnosis related group (DRG) 459 or 460. Vertebroplasty and kyphoplasty use different DRGs. National Inpatient Sample data from 2013 were queried to identify all patients that underwent lumbar fusion to treat a primary diagnosis of thoracolumbar fracture or spondylolisthesis and that were assigned DRG 459 or 460. Multivariable linear and logistic regression were used to compare length of hospital stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility for thoracolumbar fracture patients and spondylolisthesis patients. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics. The complex survey design of the NIS was taken into account in all models.

    Results: After adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26% - 44%, p<0.0001), a mean cost that was 13% less (95% CI 3.7% - 21%, p<0.0001), and had 3.6 times greater odds of being discharged home (95% CI 2.5 – 5.4, p<0.0001) than thoracolumbar fracture patients.

    Conclusions: Under the proposed DRG-based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of whether a patient had spondylolisthesis or thoracolumbar fracture. However, compared with fusion for spondylolisthesis, fusion for thoracolumbar fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. Our findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treating trauma patients.

    Patient Care: The Bundled Payment for Care Initiative (BPCI) that is being implemented by the U.S. Centers for Medicare and Medicaid Services groups lumbar fusion patients into a single payment bundle for the episode of care, regardless of the patient's underlying pathology. In reimbursing for lumbar fusion in this way, BPCI creates a systematic dis-incentive for hospitals and surgeons to treat those patients that will use more hospital resources and that are more likely to be discharged to a post-acute care facility (all of which is paid for out of the single bundle). Our study shows an example where this approach fails by comparing lumbar fusion patients with spondylolisthesis to lumbar fusion patients with thoracolumbar fracture. Unsurprisingly, the thoracolumbar fusion patients consume significantly more hospital resources and are much more likely to be discharged to a post-acute care facility. This study can improve patient care because it highlights a significant problem inherent to the BPCI as a mechanism for reimbursing for surgical care.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Have a better understanding of the bundled payment for care initiative (BPCI) from the U.S. Centers for Medicare and Medicaid Services as it relates to neurosurgery, 2) Recognize that BPCI lumps heterogeneous patient mixes with different pathologies into the same payment bundles, which creates a disincentive for hospitals and surgeons to treat certain patient groups, 3) Discuss in small groups potential solutions to the problems outlined in this presentation regarding BPCI as it relates to spine surgery


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