Can spine bundles succeed in value-based care?


Spine surgery bundled payments are more challenging to navigate than similar value-based arrangements in total joint replacement because of the wide variation of surgeries, the approaches and levels that may be operated on in any given diagnosis, as well as the significant cost differences in inpatient versus outpatient settings.

Six spine surgeons outline what's wrong with bundled payments in spine surgery and suggest changes that would benefit patients, providers and payers in these value-based arrangements. 

Question: What needs to change for bundled payments to be more widely adopted in spine surgery?

Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Many things must happen for this shift to occur. First, carve-outs are necessary for overlooked and high-risk patients, and bundles should have exclusions for medical complications that surgeons cannot control. Next, surgeons need to be able to manage all parts of the bundle, including who cares for the patient and their rehabilitation to ensure the most cost-efficient, best-quality care. I also believe more ASCs should serve as the anchors for bundles when clinically appropriate. Lastly, payers must be more transparent about data to ensure a fair bundle, so surgeons can take on the risk. 

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): For bundled payments to be more widely adopted in spinal surgery, there needs to be a standardization of payment across multiple vendors. This is perfectly suited to the ASC environment, where prices can be fixed for implants per case type and standardization of cost per case can be developed across surgeons with a particular emphasis of excluding waste (i.e., we did not need to use three biologics on a single-level fusion case).

Controlling cost to a tightly known variance can be accomplished in the ASC environment. We began approximately four years ago and now have global payments with most of the major payers. These include all providers, vendors, implants, monitoring and aftercare, as well as ASC costs, including fees for all surgeons, assistants and anesthesia. Within the cost savings that are generated, we share a portion of the savings with the surgeons to help incentivize appropriate decision making and less invasive procedures, unlike the fee-for-service model which incentivizes bigger procedures. The result has been overwhelming acceptance by the patient, payer and physicians, who are finally working together as a team to accomplish the same goal and a quality outcome.

The major impediment to a forward situation is the lack of data collection on decision making and outcomes crossed by cross-deficiency. The immense number of choices of application to care make this a difficult task, but one that — despite the work implemented — becomes a viable system for all involved. 

I see a movement forward to bundles, inclusive of global payment for care, to be the rapidly approaching future for spine. Payers and providers need to work together as we can finally align our interest, quantify outcomes and improve access and care for our patients.

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): Bundled payment programs are predetermined care payment programs for services related to a specific diagnosis related group. Developed as an alternative to fee-for-service plans, spine-related bundled payment plans have been controversial. Challenges include case complexity and distribution of risks. Some countries have been able to overcome these challenges to move in a successful implementation direction, including the Netherlands, New Zealand, Denmark, Sweden, Portugal, Taiwan and England. 

Spine surgery has high complexity procedures, which means higher risk of not achieving superior outcomes without any complications and with short length of stays. Measurements for "valued-based purchasing," which is an important concept in the discussion of bundled payment programs, includes length of stay, total cost of care, mortality and patient outcomes. The reason spine surgery is uniquely challenging for the implementation of bundled payments is because of the risk that it may discourage spine surgeons from treating the more complicated patients. 

Outlier protection is the mechanism to ensure fair compensation by insurers for those surgeries that have high risk and therefore go beyond predetermined payments. One of the main studies examining this model, which was published in 2017 by New York University Langone Medical Center in The Journal of the American Academy for Orthopedic Surgery, showed that the length of stay for spine surgery patients was unchanged and that the average episode cost during the intervention period had actually increased. The authors attributed this finding to higher rates of complex revision surgeries during the experimental group of bundled payments compared to the baseline control group. 

In conclusion, the question is not so much "what needs to change" as much as "is fair compensation even possible in this model?" The bundled model insinuates that every person fits the same mold, but yet, we know that to be untrue and we even discuss that concept with our patients during patient conversations.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I would favor the complete dissolution of the bundled payment model. Inevitably, the revenue will go toward middle management and administrators, rather than to those providing excellent care and diminishing any cost savings to the patients. If they persist, there needs to be an independent ombudsman or even a guild or union involved to advocate for the proper apportionment of payment to those doing the work. Without collective bargaining rights, physicians and surgeons will continue to lose agency and have little to no voice as larger percentages of said bundles are given to nonclinical cost bloat.

Chester Donnally, MD. Texas Spine Consultants (Addison): The concept of bundled payments sounds great. Reward those who are most efficient. This might work in joint arthroplasty where the surgeries are more uniform. However, spine has such variability in the procedure that it’s hard to compare a TLIF to another TLIF. They need to be extremely specific. Another part of bundled payments that was shown to be flawed in arthroplasty was the payments should also be based on patient demographics. Pay less for the chip-shot patients, but pay more for those that multiple studies have shown will have a higher chance of complication and readmission

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The bundled payment model is designed to encourage greater efficiency in the overall management of patients. As bundled payments emerged as a method of payment, they now accompany more Medicare reductions, which affect mostly providers with insurance indices of this kind. Better acceptance of these programs will depend on reimbursements as all patient outcomes are outlined and expected. Further cuts will only create less willingness to treat patients and disparate patient populations will continue.

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