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  • Simulating Costs for Episode-Based Bundled Payments for Cranial Neurosurgical Procedures

    Final Number:

    Zachary Adam Medress MD; Beatrice Ugiliweneza MSPH; Jonathon J Parker MD PhD; Dengzhi Wang MS; Eric MD Burton; Shiao Y Woo; Loren Baker; Maxwell Boakye MD; Stephen Skirboll MD

    Study Design:
    Clinical Research

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2019 Annual Meeting

    Introduction: Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Care Improvement Initiative (BPCI) in order to improve care coordination and cost efficiency. BPCI has been implemented for orthopedic, cardiac, and spine procedures, but has not yet been applied to cranial neurosurgical procedures. We project the cost of episode-based bundled payments for cranial neurosurgical procedures.

    Methods: We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment costs for common cranial neurosurgical procedures. Operations were classified into four groups: Craniotomy for unruptured aneurysm, craniotomy for meningioma, craniotomy for malignant glioma, and craniotomy for metastasis. We project 30-, 60-, and 90-day bundle payments for each category, and analyze the contributions of post-discharge costs to total bundle payments at each time point.

    Results: We identified 15,276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-day bundle projected costs 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 costs for a 30-day bundle and 70.5% of projected costs for a 90-day bundle. Multivariate analysis showed that medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle costs.

    Conclusions: For the first time in our knowledge, we report projected costs of 30-, 60-, and 90-day episode-based bundled payments for common elective vascular and tumor cranial operations. As previously identified in the orthopedic literature, there is significant cost variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, post-discharge costs significantly impact total bundle payments in cranial neurosurgery.

    Patient Care: The Center for Medicare and Medicaid Services introduced bundled payments as a strategy to control healthcare costs and improve health care quality in 2013. Since its introduction, bundled payments have been associated with lower overall healthcare costs, and in some cases, reduced readmission and complication rates. We believe there is merit in carefully studying the potential use of bundled payments in cranial neurosurgery, which may improve healthcare delivery and reduce healthcare costs for our patients.

    Learning Objectives: Bundled episode of care payments have been introduced in spine, orthopedic, general and cardiac surgery but have not yet been applied to cranial neurosurgical operations. For the first time, we retrospectively analyzed 25,276 episodes of care from a large administrative database to generate projected 30-, 60-, and 90-day bundled payments for four major classes of cranial operations in tumor and vascular neurosurgery. In addition to simulating projected health care costs of bundled care applied to cranial neurosurgery, a major goal of our study is to stimulate discussion about the merit of applying this health care model to cranial neurosurgery, which is inherently heterogeneous and involves complex and sick patients.


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