DRG-based bundled reimbursement for lumbar fusion: implications for patient selection

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OBJECTIVE

Under the Bundled Payments for Care Improvement (BPCI) initiative, Medicare reimburses for lumbar fusion without adjusting for underlying pathology. However, lumbar fusion is a widely used technique that can treat both degenerative and traumatic pathologies. In other surgical cohorts, significant heterogeneity exists in resource use when comparing procedures for traumatic versus degenerative pathologies. If the same were true for lumbar fusion, BPCI would create a financial disincentive to treat specific patient populations. The goal of this study was to compare hospital resource use for lumbar fusion between 2 patient populations: patients with spondylolisthesis and patients with lumbar vertebral fracture.

METHODS

The authors compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle for lumbar fusion: patients with spondylolisthesis and patients with lumbar vertebral fracture. National Inpatient Sample data from 2013 were queried for patients who underwent lumbar fusion for lumbar vertebral fracture or spondylolisthesis. Hospital resource use was measured using length of stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility and compared using multivariable linear and logistic regression. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics.

RESULTS

After adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26%–44%, p < 0.0001), a mean cost that was 13% less (95% CI 3.7%–21%, p < 0.0001), and 3.2 times greater odds of being discharged home (95% CI 2.5–5.4, p < 0.0001) than lumbar vertebral fracture patients.

CONCLUSIONS

Under the proposed DRG (diagnosis-related group)–based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of the diagnosis. However, compared with fusion for spondylolisthesis, fusion for lumbar vertebral fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. These findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treatment of trauma patients.

ABBREVIATIONS BPCI = Bundled Payments for Care Improvement; ICD-9 = International Classification of Disease version 9; ICD-10 = International Classification of Diseases version 10; LOS = length of stay; MS-DRG = Medicare severity diagnosis-related group; NIS = National Inpatient Sample.

Article Information

Correspondence Philina Yee: Center for Spine Health, Neurological Institute, The Cleveland Clinic, Cleveland, OH. pxy93@case.edu.

INCLUDE WHEN CITING Published online June 28, 2019; DOI: 10.3171/2019.3.SPINE18875.

Disclosures Dr. Steinmetz reports consultant relationships with Intellirod and Globus; clinical or research support from Globus for study described; honorarium receipt from Stryker; and receipt of royalties from Zimmer Biomet. Dr. Mroz reports a consultant relationship with Stryker and an ownership relationship with PearlDiver.

© AANS, except where prohibited by US copyright law.

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