The pros, cons of bundled payments in spine surgery: 5 insights

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Bundled payments can be used as an alternative to fee-for-service in spine surgery. Some spine surgeons believe in their potential for patient access, while others are more cautious about the arrangement.

Five spine surgeons discuss bundled payments in the industry and where they can go in the future.

Note: Responses were lightly edited for clarity.

Question: Can spine bundles attract more surgeons, practices?  

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): By offering bundled payment options for spine surgeries, ASCs can provide a more transparent and cost-effective option for both patients and providers. This can help increase patient volume and revenue for the ASC, while also attracting surgeons who are looking for streamlined payment models and increased efficiency in their practice. Additionally, spine bundles can help promote collaboration between surgeons, anesthesiologists and other healthcare providers, leading to better outcomes for patients. 

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I am not sure if "attract" is the right word. At some point, I am fairly certain we as surgeons may be forced to accept bundled payments. I think if that does happen it is a devastating mistake for the healthcare system. Surgeons will undoubtedly find better ways to make a living than taking calls at acute care hospitals. It will be a shameful moment for everyone. The best way going forward, rather than doing bundled payments and asking the foxes to guard the henhouse, is to enforce antitrust legislation, undo the exemptions from the law for monopolies that insurance companies enjoy, and pay reasonable rates. The only entity bundled payments will save money is the insurance companies. I for one do not believe hospitals and healthcare systems as they are can dutifully and ethically disperse payments appropriately. There is too much temptation for them to create new ways to not pay physicians.  

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): Spine bundles have never had a problem attracting doctors. I've been in this space for several years, and my experience is the challenges occur on the buyer side of the equation. I believe Keith Smith, MD, and Jay Kempton, founders of the Free Market Medical Association, would generally agree. Once self-funded, self-insured businesses realize they essentially function as cash buyers, they can take on a true consumer role for their companies and those they employ. Operating using cash bundles is the least time-consuming work that I do. There is no one between me and the patient. Payment occurs immediately and without hassle. I do not know any physicians with an aching desire to do more utilization reviews or hire more billing and collections personnel. If the cases are there, the providers will come. I have exclusively worked out of an ambulatory setting for almost 10 years as a spine surgeon. Other than deformity, there aren't any cases we refer, so the average community surgeon can easily transition to this model once comfortable in the outpatient setting.

What is needed is for the employer consumers to wake up to the realization of the vast sums of money they leave on the table annually. They must start asking how everyone in the room gets paid. This is the first question to ask any broker. Metrics in the insurance/broker world are not aligned with cost containment for the employer. Employers must look at their data. If they can't get data from their broker, it's time to fire the broker. The ball is in the consumer court so to speak. Based upon EOBs we have in our office, we save employers an average of $80,000 to $85,000 per spine surgery, and that is compared to their in network rate at the local hospital. If implants are used that number is into six-figures per surgery. If businesses are looking for ways to improve their bottom line, this is a no brainer. There are free market general surgery, and orthopedic surgery out there as well as spine surgery like myself and Surgery Center of Oklahoma City. My business uses free market concepts for our staff. My family and I use it too. We are far happier with the care. Even though my business now covers all employee health membership as well as DPC, including family, we spend $100k less annually for healthcare today than we did when we switched in 2019.

As businesses choose to become educated and to keep their money instead of handing it willingly to the broker/BUCA cartel, bundled markets will grow. There are already medical professionals waiting.

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): While spine surgery "bundles" may initially sound like a good idea by providing a predictable level of reimbursement for spine surgeons, one must keep in mind the original intent of such arrangements. The main reason the insurance companies are willing to create and pay for bundles is to transfer the risk of excessive costs from themselves to entities willing to accept such arrangements. Their goal is to save money, not "reward doctors for better care." By accepting bundled payment arrangements, spine surgeons accept the risks of excessive financial losses associated with complications or poor outcomes, which are quite often beyond the surgeon's control. One of the ways the surgeons might mitigate that risk is to offer surgeries in "bundled" situations only to patients who are very unlikely to have complications or poor outcomes. This would inevitably result in potentially denying medically necessary surgical interventions to patients with greater than average risk factors. I would strongly recommend for a surgeon or a practice to carefully examine their "bundle" contract before signing to understand which risks they are accepting in exchange for predictable payments.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Yes and No. Spine bundled payments, likened to orthopedic episode-based payment or packaged pricing, are a single payment based on expected costs/outcomes for clinically-defined segments of deliverable care.

Typically, spine bundled payments typically cover a sixty-day global period, facility fee, physician’s fees, anesthesiology, instrumentation costs, pain management and rehabilitation and post-operative care. Any excesses or additional risks are absorbed by the surgeon/organization. Enhanced economies of scale are added with implant savings and more rigid regimens. Ease of practice and logistics are apparent.

The idea of "all in one" packaging effort is more the nouveaux standard of care, there persists some ASC's with additional balance billing practices which are soon to be eliminated in my opinion.

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