CMS' proposed spine bundle model needs more work, surgeons say

Spine

CMS' proposed model, called the Transforming Episode Accountability Model, would bundle payments for spinal fusions and other select procedures to acute care hospitals. However, some spine surgeons feel it needs to be better developed.

The AHA on June 10 expressed concerns about the model saying the proposed model is "proposing to mandate a model that has significant design flaws, and as proposed, places too much risk on providers with too little opportunity for reward in the form of shared savings, especially considering the significant upfront investments required."

Three spine surgeons shared their thoughts about the proposed model with Becker's.

Note: Responses were lightly edited for clarity.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I feel bundling for spinal procedures on the surface to most of the accountants and insurance executives sounds like a great idea. It has some fatal flaws, however. First, no two spine surgeries are alike. There are often considerations and technical issues that can cause surgeries to last longer or patients to stay longer. Second, it is not adjusted for locale. Some surgeries cost more because they are in more expensive geographical areas. Third, it supposes that surgeons will get a fair share of the money once it ends up in the coffers of the hospital. I mean, seriously? When have the foxes guarding the henhouse worked out well for the chickens? CMS needs a refresh and needs to stop recirculating insurance people through its ranks, trying to save the insurers, and not the public, money.

Philip Louie, MD. Virginia Mason Franciscan Health (Tacoma, Wash.): I have long anticipated a bundled care package to be unveiled that includes spine surgery, given the concerns with quality/outcomes in our current fee-for-service model. While bundled payments have found some initial success within total joint arthroplasty, many spine surgeons still struggle with the idea of a broad bundle for spine fusions due to the wide spectrum of approaches/techniques, cost differences between in- and outpatient settings, as well as indications/diagnoses for these procedures.

I think the adoption of bundled payments for spine fusions will be difficult given the broad sweeping initial CMS model. Additionally, we still have not agreed on what outcomes are the most meaningful as a quality metric in spine surgical care (aside from the obvious complications and reoperations). Although, this may be the first step in coordinating our care, aligning goals towards quality (rather than quantity), and containing some of our runaway costs — there are certainly some concerns as well. One is the lack of transparency surrounding the distribution of cost savings. There are several major stakeholders that are all involved in patient care — the medical center/hospital itself, the surgeons, and those providers also participating in the episode of care. There must be defined criteria (that is agreed upon by all parties) established to create gain sharing formulas prior to entering the bundled care agreements (ie. Cost of care, quality of care, and minimum volumes achieved for eligibility in the program). A well-designed and transparent plan will avoid many disputes regarding how cost savings are eventually distributed. Each stakeholder wants to feel valued. 

Patients with complex or unexpected medical needs may not fit well into this initial TEAMS bundled payment model — and we still are working on delivering more personalized care.

There also must be boundaries/requirements that decrease the incentive to “cherry pick” healthy patients or cut-corners with regards to patient care in an effort to reduce overall costs. As there is a growing divide developing with disparities in surgical care in many regions of the country, we need to make sure that we continue to provide value-based and safe care to all communities. 

Ultimately, yes — we are headed in the direction of bundled payments, and this may be the future that we need to improve the quality of care in a cost-constrained landscape. However, with this initial rollout, I agree with the AHA, that participation should be initially voluntary, the risk adjustment needs to be revised to capture the more complex/sicker patients, and consider making participation for safety-net, rural and special designation hospitals upside only in the initial rollout. But, I will certainly be interested in how this plays out!

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The targeted surgical procedures (lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft and major bowel procedure) are usually completed by the most highly trained and skilled surgical grouping in one's health system. They are simultaneously physician leaders and community standouts who duly represent the medical community and render care to highest acuity. Without doubt, these procedures also represent substantial revenue to a health system and its lifeline. 

With that, it is another 'program relabeling' of additional scrutiny placed upon health systems and their physician pool to further limit payment schedules to the necessary continuum of complex care. Outcomes in these areas have already been established so limiting or eliminating the clinical laggards or redirection of referrals/surgeries to the better performing centers seems more appropriate and justified.  

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