Refining risk adjustment for bundled payment models in cervical fusions—an analysis of Medicare beneficiaries

BACKGROUND CONTEXTThe current Bundled Payment for Care Improvement model relies on the use of “Diagnosis Related Groups” (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1–3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology).PURPOSETo understand factors responsible for cost variation in a 90-day episode of care following cervical fusions.STUDY DESIGNRetrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5).OUTCOME MEASURESTo calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473.METHODSThe 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement.RESULTSFollowing application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (−$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (−$7,492) and Iowa (−$3,393) having the lowest reimbursements, as compared with Michigan.CONCLUSIONSThe current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.     

Alternate payment models for an episode of arthroplasty care: Are they good for patients?

Alternative payment models are proliferating and are being viewed by many as a likely path for improvement in the cost structure of health care delivery. Despite the promise to reduce the increase in spending for government and other payers, of equal importance is the impact on patient outcomes and experience. As data accumulates to address this question, it is critical that developers of such payment models follow key principles that are designed to ensure that such a significant alteration in the payment structures turn out to be beneficial for the recipients of care. Payment reform that results in improvements in factors important to patients are likely to prove durable, whereas those that threaten patient access or experience are not likely to stand.     

Alternative payment models: From bundled payments for care improvement and comprehensive care for joint replacement to the future?

Since the passage of the Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare and Medicaid Services (CMS) has been mandated to transform from a passive consumer to an active purchaser of healthcare. The goal of this article is to report on the various bundle payment initiatives [Acute Care Episode Demonstration Project (ACE-DP), Bundle Payment for Care Improvement (BPCI), and Comprehensive Care for Joint Replacement (CJR)] sanctioned by CMS, and how these innovative reimbursement systems may affect orthopedic practice. The authors will also speculate on future reimbursement systems and how they may be integrated with big data principles to further enhance the quality and efficiency of orthopedic care.     

Long vs. short fusions for adult lumbar degenerative scoliosis: does balance matters?

Purpose

Surgery of adult scoliosis was based upon coronal plane radiographical analysis using Cobb angle measurements, but recently it has been demonstrated that sagittal spinopelvic alignment plays a critical role in determining the final outcome. The aim of this paper is to compare the clinical and radiological results of 81 patients affected by adult scoliosis, treated with short or long fusions, and followed for 2–5 year follow-up.

Materials and methods

81 patients affected by degenerative lumbar scoliosis managed by posterior-only surgery were retrospectively evaluated. Fifty-seven patients underwent to a short fusion procedure, while 24 had a long fusion. Clinical and radiographic coronal and sagittal spinopelvic parameters were compared between the two groups.

Results

Coronal Cobb angle was 24° preoperatively and passed to 12° in the short fusion group, while changed from 45° to 10° in the long fusion group. Lumbar lordosis was 45° preoperatively and 60° at final follow-up in the short fusion group passed from 24° to 55° in the long fusion group. Sacral slope passed from 25° to 45° in the short fusion group, while from 10° to 40° in the long fusion group. Pelvic tilt passed from 24° to 13° in the short fusion group, and from 28° to 23° in the long fusion group.

Conclusion

Surgical treatment of degenerative lumbar scoliosis improved balance and alignment of the spine, and also the coronal plane in terms of Cobb angle. These results were associated to a consistent clinical improvement and an acceptable rate of complications.

     

Total hip replacement for displaced intracapsular neck of femur fracture. Are current guidelines appropriate for all patients? Five-year retrospective analysis of 315 cases

BackgroundAccording to the National Hip Fracture Database (NHFD), in 2018 31.4% of patients with displaced intracapsular neck of femur (NOF) fracture who, National Institute for Health and Care Excellence (NICE) viewed eligible for total hip replacement (THR), received this operation.We aimed to identify the compliance of performing THR for those patients in our unit and identify the reasons for proceeding with the alternative type of surgery.MethodsA five-year retrospective review of eligible patients was conducted between January 2014 and Dec 2018. Statistical analysis was performed between groups who did or didn't receive THR. Reasons for not performing THR were identified from pre-operative ward rounds notes.ResultsIn 2018 our unit performed THR for 44% of eligible cases. This was the highest result over five-years and higher than the national average.Out of the 348 eligible cases, pathological or undisplaced intracapsular fractures were excluded. Reminder received THR (138), hip hemiarthroplasty (166) or internal fixation (11).The average age was 77. Younger patients were more likely to receive THR than 80 years or older (p<0.05). THR group scored 0.4 points higher on AMTS and 0.2 lower on ASA scale then non-THR group (9.8 vs. 9.4 and 2.7 vs. 2.5 respectively). Mean time to surgery was 1.24 days with no significant difference between THR and non-THR group (1.6 vs. 1.1) but a slight delay to surgery during the weekends was noted (1.3 vs 1.8 days).Reasons for not performing THR were well documented as a combination of mobility restrictions and serious medical comorbidities. Retrospectively we judged the surgical decision making to be correct in 95% of cases.ConclusionsAnnual NHFD report comments on poor national and individual hospital's compliance with NICE guidelines without allowing surgeons to justify their choice of the procedure undertaken.Surgical decisions are made in a highly specialised multi-disciplinary environment taking into consideration individual patient's frailty and potential morbidity. Details of those discussions should be collected in NHFD to allow further analysis of reasons why surgeons decide not to offer THR to a patient NHFD views as eligible for this procedure. This could help in understanding the complex factors impacting on decision making in those cases.Level of evidence:Level III     

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Background

Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited.

Questions/purposes

We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained?

Methods

We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors.

Results

There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor.

Conclusions

There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care.

Level of Evidence

Level II, economic analysis.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4445-0) contains supplementary material, which is available to authorized users.     

Are current measurements of lower extremity muscle architecture accurate?

Skeletal muscle architecture is defined as the arrangement of fibers in a muscle and functionally defines performance capacity. Architectural values are used to model muscle-joint behavior and to make surgical decisions. The two most extensively used human lower extremity data sets consist of five total specimens of unknown size, gender, and age. Therefore, it is critically important to generate a high-fidelity human lower extremity muscle architecture data set. We disassembled 27 muscles from 21 human lower extremities to characterize muscle fiber length and physiologic cross-sectional area, which define the excursion and force-generating capacities of a muscle. Based on their architectural features, the soleus, gluteus medius, and vastus lateralis are the strongest muscles, whereas the sartorius, gracilis, and semitendinosus have the largest excursion. The plantarflexors, knee extensors, and hip adductors are the strongest muscle groups acting at each joint, whereas the hip adductors and hip extensors have the largest excursion. Contrary to previous assertions, two-joint muscles do not necessarily have longer fibers than single-joint muscles as seen by the similarity of knee flexor and extensor fiber lengths. These high-resolution data will facilitate the development of more accurate musculoskeletal models and challenge existing theories of muscle design; we believe they will aid in surgical decision making. Two of the authors (SRW, RLL) have received funding from National Institutes of Health Grants HD048501 and HD050837 and the Department of Veterans Affairs. Each author certifies that his or her institution has approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.     

Should the Medicare ESRD Program Pay for Daily Dialysis? An Ethical Analysis

End-stage renal disease (ESRD) is a growing problem in the United States and has now reached epidemic proportions. The mortality rate and other complications related to conventional dialysis remain unacceptably high necessitating improvements in dialytic therapies. One strategy has been to increase dialysis frequency through daily dialysis since the Hemodialysis study showed that clinical outcomes are not improved by simply increasing delivered dialysis dose per session. Most studies of daily dialysis are observational and limited by small sample size, variable dialysis techniques, high patient dropout, and lack of adequate control group. These studies have shown consistent improvements in blood pressure and solute clearance, but improvements in patient survival, anemia, and health-related quality of life are less clear. The costs of providing daily dialysis on a large scale are likely to be substantial. However, if there are significant improvements in the outcome measures outlined earlier as well as decreased hospitalization rates, daily dialysis may prove cost-effective or budget neutral from a global standpoint. A scientific basis is needed to justify a change in the Medicare ESRD Program to fund daily dialysis. Decisions regarding the allocation of limited medical resources such as the Medicare budget should consider ethically appropriate criteria including likelihood of benefit, urgency of need, change in quality of life, duration of benefit, patient selection, equitable distribution, and the amount of resources required. In examining the evidence base on daily dialysis according to these ethical criteria, we find that there are not yet sufficient grounds to recommend funding of daily dialysis by the Medicare ESRD Program. Randomized controlled trials comparing conventional hemodialysis to short daily and long nocturnal hemodialysis are much needed.     

Survivorship analysis of 150 consecutive patients with DIAM? implantation for surgery of lumbar spinal stenosis and disc herniation

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1–48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4–5; 31, L5–6) and 4 two-level (L4–5 and L5–6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5–6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan–Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2–29 months). Kaplan–Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5–6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4–5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5–6 [hazard ratio (HR), 10.3; 95% CI, 1.7–63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2–90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5–6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4–5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5–6 and two-level in patients with LSTV are significant risk factors for reoperation.     

Are stand‐alone cages sufficient for anterior lumbar interbody fusion?

Anterior lumbar interbody fusion (ALIF) has increased in popularity because it has advantages over posterior fusion. Because there is disagreement about the stability of stand‐alone cage ALIF, some surgeons use various types of supplementary fixation, including anterior plates, pedicle screw systems and translaminar screws, to increase segmental stability. Many factors associated with both the cages and endplates influence the time of onset and extent of subsidence after use of stand‐alone cage ALIF. A large round cage with an adequate central opening is recommended to facilitate maximum contact with the periphery of the endplate. With regard to the relationship between radiographic fusion and recurrence of symptoms with the development of subsidence, most researchers have reported finding no correlation. Subsidence may be due to a process of bone incorporation between cages and endplates. Does subsidence or nonfusion really matter clinically? Further prospective, randomized controlled trials are very much needed to answer these questions.     

What is the role of neurosurgeons in the current management of intracranial aneurysm in France? An analysis of professional practices

Study DesignRetrospective observational survey-based study.IntroductionIn France, intracranial aneurysm (IA) patients are managed by neurosurgeons and by interventional neuroradiologists. The growth of endovascular treatment led us to reflect on the role of neurosurgeons in the management of patients with IA. The present study aimed to highlight the current organization of IA management in France.MethodA 60-question survey was sent to the neurosurgeons in 34 hospitals managing IA patients. Thirty-three questions dealt with standards of care, follow-up procedures and the involvement of the specific specialist.ResultsTwenty-seven centers (79.4%) responded to the survey. A Vascular Multidisciplinary Discussion Team was organized, including both surgeons and neuroradiologists, in 92% of responding centers. There were department protocols in 66% of centers, a local registry in 33% and clinical trials in IA in 60%. Patients with unruptured IA were first seen by a neurosurgeon or by an interventional neuroradiologist, with different practices. For ruptured IA, the neurosurgeons were contacted first in 93% of cases, and were systematically involved in initial intensive care unit management. The patients were hospitalized in the neurosurgery department in 89% of the centers. The neurosurgeons took care of initial follow-up in 85% of the centers, and of lifetime follow-up in 36%. In most centers, radiological monitoring of IA was based on MRI angiography for patients who were embolized or under surveillance, and on CT angiography after microsurgery.ConclusionDespite the growth of endovascular treatments, the present survey and the literature highlight a major role of neurosurgeons in treatment, follow-up and care coordination.     

Green light for liver function monitoring using indocyanine green? An overview of current clinical applications

The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri‐operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra‐abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, ‘hard’ evidence – i.e. high‐quality prospective randomised controlled trials – is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.     

Does the method of payment affect anaesthetic practice? An evaluation of an Alternate Payment Plan

Purpose

To test the null hypothesis that the method of physician payment does not influence the practice of anaesthesia.

Methods

Retrospective cohort study of anaesthetists before (Jan–June. 1994) and after (Jan–June. 1995) departure from fee-for-service practice into an alternate funding arrangement (AFP). Another group of physicians was studied as a concurrent control. Case numbers, induction times, cancellation rates, and operating hours for the department, recorded by third parties, were compared before and after AFP implementation Using index procedures, details of individual patient decisions made by anaesthetists were compared for the two study periods, and between subscribing and non-subscribing physicians.

Results

Implementation of AFP resulted in a modest reduction in case numbers (7.2%) offset by an increase (5.7%) in the average case duration. Net change in time dedicated to clinical service (2% per physician) is inconsequential to the academic mission of the department. There was no change in cancellation rate and the use of invasive monitors was unchanged. An increase in the use of regional anaesthesia occurred but. since a similar increase occurred in the practice of those still on fee-for-service, it cannot be ascribed to the AFP. With respect to hip arthroplasty, the case was prolonged (P=0.00l) if the surgeon was paid via the AFP.

Conclusion

Payment of physicians by non-fee-for-service techniques did not have a constructive influence on measures of anaesthetic practice. The goal of alternate payment arrangements, to liberate time for academic pursuits, could not be achieved in this experimental model.