I'd like to thank the AANS for the privilege of presenting our work on predicting determinants of variation in episode of care bundled payments for adult spinal deformity surgery. I have no disclosures. By way of introduction, the Bundled Payment for Care Improvement Program, or BPCI, was introduced in 2012 by CMS as an alternative payment strategy to promote cost efficiency. By definition, bundled payments encourage collaboration and efficiency between providers, hospitals, and outpatient services in order to contain costs and reward high-value and high-quality care. This program has been introduced for joint replacement, cardiac, general surgery, and short-segment spinal fusions, but has not yet been applied to adult spinal deformity surgery. So far, this program has been successful and has shown cost savings and improvements in quality metrics in the orthopedic literature, and the BPCI was expanded in 2018 in a program called BPCI Advanced, which included 29 inpatient and three outpatient conditions. Hospital insurers have started following suit, and they have offered bundled payments optioned to providers in some settings. Now adult spinal deformity surgery is associated with high costs. Other studies have shown that primary hospitalization can cost over $120,000, with an additional $67,000 per readmission, and overall, this has accounted for over $1.7 billion in health care costs over the last decade in the managed care population. In addition to this, adult spinal deformity surgery may be targeted in future iterations of bundled payment programs due to their high cost, significant variability in surgical approach, instrumentation, outcomes, and payments. The objective of our study was to generate projections of 30-, 60-, and 90-day episode-based bundled payments for adult spinal deformity operations using retrospective data from a large commercial claims database. We then used these projections to predict the impact of payer status, surgical approach, complications, and readmissions on bundle prices in order to understand how bundled payments may affect adult spinal deformity surgery. We used the market scan database to retrospectively identify these patients who underwent primary surgery for adult spinal deformity from 2007 to 2016. We found over 8,000 cases. We excluded any patient that was under 18 years of age, any patient with a history of tumor or trauma, or any patient undergoing anterior only deformity correction. We defined an episode of care as the index hospitalization plus any readmission or outpatient services rendered within a given epoch. We performed simulations for 30-, 60-, and 90-day epochs. Moving on to the results, these are our demographics and baseline characteristics of the cohort. The median age was 51 years. The range was 18-88 years. We had over 70% of the patients as females. And these are some of the baseline characteristics, including the rate of osteoporosis and other comorbidities. We did have 25% of patients with commercial insurance and the remainder with 75% with Medicare. In terms of operative characteristics, in terms of our cohort, we had over 95% undergoing a posterior only surgical approach as opposed to a posterior plus anterior lateral approach. And we found that over 11.5% of patients received BMP as a surgical adjunct in the case. We then calculated the index hospitalization payment and showed that the index hospitalization payment in total was $127,000. We moved on to calculate 30-, 60-, and 90-day bundle prices and showed that the 30-day bundle price was $186,000, whereas the 60- and 90-day bundle prices were $190,000 and $192,000. We then looked at the discharge disposition and readmission rates of our cohort, given that these factors have been important in affecting bundle values in both the orthopedic and spine literature. In our cohort, 55% of patients were discharged home, with the remainder requiring some kind of post-acute services, whether that was home health, skilled nursing facility, or rehab rehabilitation center. We also saw that 17%, 20%, and 21% of patients were readmitted for 30-, 60-, and 90-day bundles respectively. We also wanted to understand the impact of preoperative and operative characteristics on bundle values at 30-, 60-, and 90-days. On our multivariable regression analysis, we found that private insurance was associated with a 29% increase in bundle value at 30-days. We also found that age had a positive effect on bundle value, whereas gender did not have a statistically significant effect on bundle value. In terms of preoperative comorbidities, we found that patients with osteoporosis had a small but statistically significant increase in bundle value at 2.4% for a 30-day bundle, whereas patients who had baseline paraparesis had a 9.1% increase in bundle value at 30-days. In terms of operative characteristics, we found that BMP use was not associated with a statistically significant change in bundle value at 30 or 60-days. However, it was associated with a statistically lower bundle value at 90-days. We also looked at approach type and found that a combination anterior or lateral plus posterior approach was associated with an increased bundle value at 30-days, 13%. We also wanted to look at the effect of postoperative characteristics and complications on bundle values, and we also used the multivariable regression analysis to perform this. We found that postoperative hematoma had a profound effect on bundle value with a 31% increase in bundle value at 30-days. DVT was also associated with a large increase in bundle value at 21.8% at 30-days, and discharge disposition was also associated with increased bundle values with a discharge to an inpatient rehabilitation center associated with a 15% increase in bundle value. For those patients that required reoperation within a given epoch, this was associated with a large increase in bundle value with reoperation within 30-days being associated with a 28% increase in bundle value. Moving on to our conclusions, we defined 30-, 60-, and 90-day bundle values for adult spinal deformity surgery at $186,000, $190,000, and $192,000, respectively. We showed that baseline preoperative characteristics, surgical approach type, discharge destination, and postoperative complications significantly impacted bundle values at 30-, 60-, and 90-day episodes of care. Based on these data, we predict that expansion of bundle payments to include adult spinal deformity surgery would have profound long-term ramifications for patient selection, surgical approach, and practice patterns for adult spinal deformity surgery in the United States. I do want to acknowledge some limitations of the study. Commercial databases do not include important clinical and technical information about adult spinal deformity operations, including the preoperative severity of the deformity, the number of levels included in the operation, the presence and type of osteotomies performed. I also want to note that bundle payments, for the most part, are a Medicare-only program. Yet the data we used draws from a mix of Medicare, Medicaid, and private payer insurance. These are my citations to co-authors on the study. Thank you for your attention.

bundled payment programs

adult spinal deformity surgery

cost efficiency

projections of bundled payments

long-term ramifications