Bundled Payment Models in Spine Surgery: Current Challenges and Opportunities, a Systematic Review

BACKGROUND: Bundled payments offer a lump sum for management of particular conditions over a specified period that has the potential to reduce health care payments. In addition, bundled payments represent a shift toward patient-centered reimbursement, which has the upside of improved care coordination among providers and may lead to improved outcomes. OBJECTIVE: To review the challenges and sources of payment variation and opportunities for restructuring bundled payments plans in the context of spine surgery. METHODS: We reviewed episodes of care over the past 10 years. We completed a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model in PubMed and Ovid databases to identify studies that met our search criteria. RESULTS: Ten studies met the search criteria, which were retrospective in design. The primary recipient of reimbursement was the hospital associated with the index procedure (59.7%-77% of the bundled payment), followed by surgeon reimbursement (12.8%-14%) and post-acute care rehabilitation (3.6%-7.3%). On average, the index hospitalization was $32,467, ranging from $11,880 to $107,642, depending on number of levels fused, complications, and malignancy. Readmission was shown to increase the 90-day payment by 50%-200% for uncomplicated fusion. CONCLUSIONS: The implementation of spine surgery in bundled payment models offers opportunity for health care cost reduction. Patient heterogeneity, complications, and index hospitalization pricing are among factors that contribute to the challenge of payment variation. Development of standard care pathways, multidisciplinary coordination between inpatient and outpatient postoperative care, and empowerment of patients are also key elements of progress in the evolution of bundled payments in spine surgery. We anticipate more individualized risk-adjusted prediction models of payment for spine surgery, contributing to more manageable variation in payment and favorable models of bundled payments for payers and providers.