Recent dropout rates in CMS' Bundled Payments for Care Improvement program suggest that participation barriers and retention strategies need to be addressed to have a more significant effect on healthcare cost and quality, according to an article published in the Journal of the American Medical Association.
While bundled payments have found some success in joint replacement, many industry leaders remain unsure if the value-based program can achieve similar success in spine surgery due to the wide variation of surgeries, approaches and levels that may be operated on in any given diagnosis, as well as the cost differences based on in- and outpatient settings.
Eight surgeons share thoughts on bundled payments in spine and orthopedics.
Note: Responses are lightly edited for style and clarity.
Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): At one point, I thought [bundled payments] was the future. We were all in to measure and get our metrics prepared for this. In spine, it has been a lot fits and starts, it hasn't really panned out. Total joints are pretty uniform; every total hip replacement looks about the same. Spine is just a different animal. A bundle for a lumbar fusion up to five levels encompasses so many different pathologies and the economics of those are so different. We have tried within our group to be part of Medicare bundles and accept different types of care, and that has been difficult to do in spine. It hasn't really taken off like it has in joints and other areas of orthopedics. I still think the principle of value based care will stay, there is no doubt, but it's a tough thing in spine to execute. Obviously payers want to move away from fee for service and we at the same time have to prove the value of what we do. But formal value based programs have been very elusive in spine. I think we should collect data, and it's important that all practices do it; if you don't you'll be in trouble. But is it going to be the way of the future that people have talked about? I'm less certain of that than I might have been three or four years ago.
Andrew Hecht, MD. Mount Sinai Health System (New York City): We have not participated in bundled payments for spine. After careful analysis and due to the variability of techniques, instrumentation implant cost and other variables, we found it to be a relatively high risk, low reward proposition. It would only work for the most basic of cases and not for anything else. If complications should occur, it would shift all the risk to the institution. Bundled payments are much more reliable for more straightforward problems like hip and knee arthritis. Surgeons and institutions need to be very careful with assessing the type of bundled payment arrangements they are entering into. After our careful analysis and research, we found it would be cost effective only in a very limited number of cases and types of cases.
Alexander Vaccaro, MD. Rothman Orthopaedics (Philadelphia): We were in bundled payments for the last 10 years, and we did great. We had shared savings with the insurance company and with the hospital. What happens is the growth change every year, the better you get the more difficult to get to save money, so we're now bottomed out. In the federal government and a lot of their value based systems, we're actually dropping out of a lot of them because we can't get any more efficient. We can get a hip fracture to the operating room within 24 hours and we can get them out of the hospital to a rehab or a home within one to two days; we've done everything. We looked at everything that we could sort of squeeze out any inefficiencies. The next step is population based medicine where you do per patient, a per member per month, per member, per year arrangements.
Mark Mikhael, MD. Illinois Bone & Joint Institute (Des Plaines): [We have] been participating in bundled payments in spine surgery for several years. Lumbar, thoracic and cervical fusions are included in these bundled payment programs. The success of our program is due to a collaborative effort between IBJI and our partners in physical therapy, home health services, social services and skilled nursing facilities. We have a unified goal to provide high-quality care throughout the preoperative, perioperative and postoperative period through patient education and surgical standardization. These efforts have led to shortened postoperative hospital stays, more frequent discharge to home after surgery (with home health services), and minimized skilled nursing facility stays when necessary. Along with preoperative patient education to set expectations, the program encourages early postop mobilization, enhanced recovery after surgery protocols by anesthesia providers and minimal opioid analgesia. The success of the program would not be possible without a coordinated effort with our care partners.
Mick Perez-Cruet, MD. Michigan Head & Spine Institute (Southfield, Mich.): We haven't participated [in bundled payments for spine] but I feel we are headed in that direction. The advantage is that it potentially promotes cost savings, however, I feel a much more effective method to reducing spine care cost is to incentivize surgeons who perform cost-effective care. These cost savings should not solely be realized by the hospital or insurance carriers as they don't ultimately decide the treatment plan, nor fully understand what is in the best interest of the patient. Those surgeons that clearly reduce cost yet provide outstanding clinical care should be rewarded for doing so. These rewards should be significant. I know in my practice that providing minimally invasive outpatient spine care has clearly reduced costs and patients are very satisfied with their outcomes. Additionally, efforts to provide transparency in spine care cost can also be effective. Nobody goes shopping without knowing ahead of time the cost, or at least they should not. Instituting these same measures in healthcare might go a long way in reducing costs while still providing outstanding spine care.
William Rambo, MD. Midlands Orthopaedics & Neurosurgery (Columbia, S.C.): Our group recently included eight spine surgeries in the bundled surgery menu on our website. All spine bundles include the surgeon and assistant fees, ASC facility fee, implants, anesthesia and 90 days of routine follow-up care. As healthcare purchasers clamor for price transparency, we expect 2021 to bring us more patients, self-funded employers and their third-party administrators who appreciate our easily accessible pricing menu.
Fred Harris, MD. Twin Cities Orthopedics (Golden Valley, Minn.): I found that [bundled payments] have been very efficient and rewarding in ASCs with the right patient selection. Patients that undergo anterior cervical spine surgery usually leave the surgery center and go to our care suites and stay overnight. Lumbar fusion patients usually stay up to two nights in the care suites prior to discharge home. My request for spine bundle care in the ASC has significantly increased over the past year.
Owen O'Neil, MD. Twin Cities Orthopedics (Golden Valley, Minn.): Whenever you develop a bundle — whether it's a total hip or knee replacement or a spine bundle — one has to look at technology and devices. It's really important that we ensure an efficient use of those devices and that we work diligently with the vendors to get products that are tried and proven, but that also create value within the system. Also, when developing bundles, it is key to medically optimize patients preoperatively so that medical complications are decreased postoperatively while in the bundle.