Robert Florin, MD Resident Award- Savings Associated With Bundled Payments for Outpatient and Inpatient Spine Surgery Episodes

Introduction: Only a few value-based payment programs have included spine surgery, and these did not previously include any outpatient surgery. Beginning in 2018, the Centers for Medicare and Medicaid Services introduced Bundled Payments for Care Improvement – Advanced (BPCI Advanced), the first episode-based payment model to include an outpatient surgical condition: spine surgery. For the first time, this study examines spending and quality for outpatient versus inpatient surgical bundles; specifically, this study determines whether hospital participation in BPCI Advanced for outpatient and inpatient spine surgery (back and neck except spinal fusion procedures, BNESF) was associated with changes in spending and quality.

Methods: This was a retrospective observational study using Medicare claims and differences-in-differences analysis adjusting for patient and market characteristics. We included Medicare beneficiaries receiving outpatient and inpatient BNESF between 2013 and 2019 at hospitals that participated in BPCI Advanced versus a matched comparison group of non-participating hospitals. The primary outcome was total episode spending, including spending incurred for the index procedure and 90-day follow-up period. Secondary outcomes included 90-day readmissions, emergency department visits, and mortality.

Results: Among 14,280 patients who received outpatient BNESF, hospital participation in BPCI Advanced was associated with a differential reduction in total episode spending (-$1201 (95%CI -2184 to -219)) and readmissions (-2.2 percentage points (95%CI -4.2 to -0.1). Among 23,440 patients who received inpatient BNESF, hospital participation in BPCI Advanced was not associated with differential changes in total episode spending or readmissions. There were no significant changes for emergency department visits or mortality for either group.

Conclusion : Participation in a bundled payment program for outpatient spine surgery was associated with lower spending and fewer readmissions. No changes in spending or quality were observed for similar inpatient spine surgery procedures. Further evaluation of outcomes for outpatient surgical conditions is needed to inform expansion of future bundled payment models.