Bundled payment programs assume a level of uniformity that spine surgery patients often don’t have, and for value-based medicine to work, surgeons say that models should address the nuance.
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Question: With value-based care models expanding, what’s the biggest structural barrier preventing spine surgery from fitting cleanly into bundled payment programs?
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Patient heterogeneity and our collective reluctance to be honest about it is the biggest barrier.
Bundled payments work well when the patient population is reasonably homogeneous, the intervention is well-defined and the outcomes are measurable within a clinically meaningful timeframe. Spine surgery fails all three criteria at scale.
The patient presenting for lumbar fusion after a motor vehicle accident with adjacent segment disease, prior laminectomy, obesity, depression, and chronic opioid use is not the same patient as the active 55-year-old with single-level spondylolisthesis. But bundled payment programs routinely treat them as equivalent — same DRG, same bundle, same expectation of outcomes and cost. The result is that surgeons and systems operating in value-based models have a powerful financial incentive to select the healthier, simpler patients and avoid the complex ones. That’s risk selection dressed up as efficiency.
The structural change that would actually work is risk stratification sophisticated enough to reflect the real drivers of outcomes in spine surgery: social determinants, psychological comorbidities, prior surgical history, and whether the indication for surgery was strong to begin with. Until bundles can incorporate those variables meaningfully, we’re rewarding patient selection rather than care quality.
The most consequential decision in spine surgery, whether to operate at all, is not captured in any bundle. If we want value-based models to actually improve spine care, we need to measure and reward appropriate non-operative care as rigorously as we measure surgical outcomes.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Value-based medicine and its concerted payment process require collective agreement among physicians in diagnosis, treatment and post-operative management. Comorbidity variance, level of surgical complexity, potential complication rates and patient compliance are suppositional issues that remain lessened within a patient’s acuity presentation and ultimate outcome. Bundled episodic payments establish a prospectively defined payment for all services associated within a discrete incidence of care, supporting a greater predictability of spending and not an actual and predictable outcome for the more complex patient population. The true level of case complexity is not realized through current and semi-accurate data reporting and will require further implementation.
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