- Email: [email protected]
Costs Associated With a 90-Day Episode of Care After Single-Level Anterior Lumbar Interbody Fusion
Journal Pre-proof Costs associated with a 90-day Episode of Care following a Single-Level Anterior Lumbar Interbody Fusion (ALIF) Azeem Tariq Malik, MBBS, Selina Deiparine, BA, Safdar N. Khan, MD, Jeffery Kim, MD, Elizabeth Yu, MD PII:
S1878-8750(19)33149-3
DOI:
https://doi.org/10.1016/j.wneu.2019.12.117
Reference:
WNEU 13964
To appear in:
World Neurosurgery
Received Date: 18 November 2019 Revised Date:
18 December 2019
Accepted Date: 19 December 2019
Please cite this article as: Malik AT, Deiparine S, Khan SN, Kim J, Yu E, Costs associated with a 90-day Episode of Care following a Single-Level Anterior Lumbar Interbody Fusion (ALIF), World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.117. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Costs associated with a 90-day Episode of Care following a Single-Level Anterior Lumbar Interbody Fusion (ALIF) Azeem Tariq Malik, MBBS, Selina Deiparine, BA, Safdar N Khan, MD, Jeffery Kim, MD, Elizabeth Yu, MD Department of Orthopaedics, The Ohio State University Wexner Medical Center Short Title: 90-Day Bundle for ALIF Corresponding Author: Elizabeth Yu, MD Associate Professor Fellowship Director, Orthopaedic Spine Department of Orthopaedics Division of Spine Surgery The Ohio State University Wexner Medical Center Tel: 614-293-0706 Fax: 614-293-6250 Email: [email protected]
Keywords: anterior lumbar interbody fusion; costs; bundled payment; Humana; Medicare advantage; Commercial; ALIF
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Abstract Introduction Anterior Lumbar Interbody Fusion (ALIF) is a commonly performed surgical procedure for the management of degenerative lumbar spine pathologies. Despite an increasing number of ALIFs being performed nationally, no study has evaluated the costs associated with the 90-day episode of care following the surgery. Materials and Methods: The 2007-2016 Humana Administrative Claims (HAC) dataset, a national database of Commercial and Medicare Advantage (MA) beneficiaries, was queried using Current Procedural Terminology code 22558 for patients undergoing single-level ALIFs. Ninety-day costs were defined on the basis of the following categories (facility, surgeon, anesthesia, other hospitalization costs and services, radiology, office visits, physical therapy/rehab, emergency department visits and readmissions). Results: A total of 365 ALIFs (MA=244; Commercial=121) were included in the analysis. The average 90-day cost of single-level ALIF was $25,568 and $51,741 for MA and Commercial enrollees respectively. The major proportion of 90-day costs was attributable to facility reimbursements (74%-76%), followed by surgeon costs (9%-11%). Post-acute care (office visits and physical therapy/rehab) were not major drivers of 90-day costs, consisting of only 0.7%-1.3% of the total 90-day reimbursement. Among patients who got readmitted, the cost of the readmission increased the average 90-day cost by 65%-66%. Conclusions: Facility costs were the major driver of a stipulated 90-day reimbursement for patients undergoing a single-level ALIF. Health-policy makers and providers can utilize this data to better understand the distribution of costs in a stipulated bundled-payment model for ALIFs, and allow them to identify areas where cost-reduction strategies can be carried out.
41 42
Introduction At present, the per capita spending of the U.S. healthcare system far exceeds that of any
43
other country in the world1. The lack of a cost-saving incentive in the current fee-for-service
44
model (i.e. providers are reimbursed individually by each service supplied), compounded with
45
continuously rising prices2 are contributing to a high economic burden. This economic burden
46
has precipitated health-policy makers to focus around driving value, rather than volume, in
47
healthcare. In order to curtail costs associated with expensive surgical conditions particularly,
48
health-policy makers have increasing looked at alternative payment models, such as episodic
49
bundling, to introduce the concept of financial risk-sharing, in order to maintain and/or increase
50
quality while reducing costs3-7. Episode-based bundling is essentially based on the principle of
51
distributing payments, out of a single pre-defined “bundled target payment”, to all service
52
providers (hospitals, physicians, and post-acute care) associated with an “episode of care”8,9.
53
While the duration of the episode-of-care can vary anywhere between inpatient-only to up to 90-
54
days, most bundled payments for orthopaedic surgical conditions (i.e. hip fractures10, spinal
55
fusions11,12 and total joint arthroplasties13,14), largely revolve around a 90-day bundled period
56
which begins on the day of surgery and ends at the 90-day follow-up time.
57
More than 400,000 spinal fusions are performed in the United States alone every year,
58
generating an annual cost-burden of more than $33 billion15,16. Furthermore, given that lumbar
59
fusions are among the top three conditions of Medicare expenditure17, these surgeries offer a lot
60
of opportunity for implementing value through bundled payments. While posterior lumbar
61
fusions still remains the most common approach for performing lumbar fusions, due to
62
expanding indications and technical improvements, there has been a relative rise in the use of
63
anterior lumbar fusions for the management of degenerative spinal pathology18. Despite the
64
increase in the number of anterior lumbar fusions performed and the broader focus on value, no
65
study to date has evaluated the distribution of costs associated with a 90-day episode of care
66
following a single-level anterior lumbar interbody fusion (ALIF). An understanding of the costs
67
associated with this specific procedure would be essential for identifying potential areas for cost
68
reduction and optimizing value through bundled payment models. In the light of the latter
69
observations, we sought to utilize a national insurance claims dataset to understand the
70
distribution of 90-day costs following a single-level ALIF for degenerative spinal pathology.
71 72
Methods
73
Database and Patient Selection
74
This was a retrospective study performed using the Humana Administrative Claims
75
(HAC) database. The HAC database is a comprehensive source of insurance claims from over 20
76
million Commercially-insured and Medicare Advantage (MA) beneficiaries across the nation.
77
The data is stored on a super-computer, and is made available to users (on a subscription basis)
78
through the PearlDiver research software. The claims can be queried using a unique coding
79
language that utilizes combinations of International Classification of Diseases 9th/10th Edition
80
(ICD-9/ICD-10) diagnosis codes, procedure codes and Current Procedural Terminology (CPT)
81
codes. All data retrieved from the HAC database is presented in a de-identified format, and the
82
study, therefore, was exempt from Institutional Review Board (IRB) approval. Further details
83
regarding the PearlDiver research software and the HAC database can be found on the official
84
website (www.pearldiverinc.com).
85 86
The 2007-2016 HAC data files were queried using CPT codes 22558 to identify patients undergoing single-level ALIFs. Patients undergoing multi-level fusions, adjunct posterior
87
fusion/instrumentation, fusion for deformity/trauma/malignancy and those with missing data
88
with excluded from the study. The before-mentioned exclusion criteria were applied to ensure
89
that only patients undergoing single-level ALIFs for degenerative spinal pathology were
90
included in the final cohort. Patients who had incomplete follow-up during the 90-day post-
91
operative period, or those who died during the 90-day post-operative period were also excluded.
92
Since Medicare Advantage and Commercial plans have starkly different reimbursement
93
rates/policies, the study cohort was divided into two cohorts (Medicare Advantage or
94
Commercially-insured) and analyzed separately
95
Ninety-Day Cost Categories
96
The terms “costs”, “payments” and/or “reimbursements”, used interchangeably
97
throughout the manuscript, refer to the actual payments made by the insurance company to
98
service providers, and are not “charges” (payments claimed by hospitals). Ninety-day costs were
99
defined on the basis of the following categories 1) facility costs – which included payments
100
made to the hospital, as well as implant costs, 2) surgeon (payments made to the operating
101
physician), 3) anesthesia (payments made to the anesthesiologist), 4) Other hospitalization
102
costs/services (costs attributable to ancillary investigations, such as labs etc.), 5) radiology, 6)
103
office visits, 7) physical therapy/rehab (included both skilled nursing facility, outpatient
104
rehabilitation and inpatient rehabilitation), 8) emergency department (ED) visits and 9)
105
readmissions. A complete list of codes used to retrieve the before-mentioned categories can be
106
found in the Appendix. Descriptive analysis was used to report the average cost/reimbursement
107
for each category, as well as the entire 90-day episode of care, for each patient.
108
109 110
Results Following application of inclusion/exclusion criteria, a total of 365 patients undergoing a
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single-level ALIF for degenerative spinal pathology were included in the study. Out of the 365
112
ALIFs, 244 were performed in Medicare Advantage beneficiaries and 121 were performed in
113
Commercial beneficiaries. The average 90-day cost of single-level ALIF was $25,568 and
114
$51,741 for Medicare Advantage and Commercial beneficiaries respectively.
115
Medicare Advantage Beneficiaries
116
A detailed description showing the average cost/category for Medicare Advantage
117
beneficiaries can be seen in Table 1 and Figure 1. The major proportion of 90-day costs was
118
attributable to facility reimbursements (76.4%), followed by surgeon costs (11.5%). Costs
119
attributable to anesthesia and other hospitalizations services constituted 1.7% and 0.9% of the
120
total 90-day cost, respectively. Post-acute care (office visits and physical therapy/rehab) were not
121
major drivers of 90-day costs, consisting of only 1.3% of the total 90-day costs. Even though
122
readmissions themselves contributed around 7% of the total 90-day cost, among patients who got
123
readmitted (N=27; 11.1%), the average cost of the readmission ($17,058) increased the average
124
90-day cost by 66.7%.
125
Commercial-only Beneficiaries
126
A detailed description showing the average cost/category for Medicare Advantage
127
beneficiaries can be seen in Table 1 and Figure 2. Facility costs were responsible for around 74%
128
of the total 90-day reimbursements, followed by surgeon costs (9.4%). Costs attributable to
129
anesthesia and other hospitalizations services constituted 3.4% and 0.3% of the total 90-day cost,
130
respectively. Post-acute care (office visits and physical therapy/rehab) constituted only 0.7% of
131
the total 90-day costs. Even though readmissions themselves contributed around 11% of the total
132
90-day cost, among patients who got readmitted (N=7; 5.8%), the average cost of the
133
readmission increased the average 90-day cost by 65.5%.
134 135
Discussion
136
Although the United States spends more per capita on health delivery/care than any other
137
nation, the country’s system still ranks last, among industrialized nations, on overall performance
138
and quality of healthcare19. Alternative payment models such as episodic bundling represent a
139
potential solution to the rising costs of care and high economic burden of the current health care
140
system. Maximizing value in such bundled models will require an understanding of the
141
distribution of costs associated with care for specific procedures, which will aid providers and
142
health policy-makers in identifying appropriate targets for quality improvement. As evidenced in
143
our study, in a stipulated 90-day bundled payment model for single-level ALIFs, facility costs
144
are responsible for the greatest share of (74.0%-76.4%) of reimbursements. This is consistent
145
with previous analyses, which have shown that facility costs such as surgical implants, length of
146
inpatient stay, and operating room time contribute approximately 73%-92% of the total 90-day
147
costs20,21. Given the latter findings, optimizing facility costs through either improving/shortening
148
inpatient length of stay or aggressive contracting/value-based purchasing of implants, can be an
149
effective way of bringing down costs across the entire episode of care. Another way of reducing
150
facility costs is by transitioning surgery to outpatient/ambulatory surgery centers for a carefully
151
selected low-acuity patient population. With the advent of minimally invasive technology that
152
allows minimal exposure and quick recovery, it is likely that outpatient spinal fusions become
153
readily prevalent in the upcoming decade.
154
Post-acute services (office visits and physical therapy/rehabilitation services) did not
155
contribute greatly to the total cost of the 90-day episode, consisting of 0.7%-1.3% of the total
156
reimbursement. While post-acute costs have been previously found to comprise approximately
157
36-38% of bundled costs for total joint arthroplasty22,23, they do not appear to constitute a
158
significant proportion of 90-day costs for spinal fusions. This findings highlights the importance
159
of focusing on optimizing facility costs to bring about value in patients, rather than simply
160
resorting to increasing the proportion of home discharges. For commercially insured patients,
161
readmission-related reimbursements were responsible for second largest share of total cost
162
(11.1%), while such payments comprised the third largest share of the 90-day total for Medicare
163
Advantage enrollees (7.4%). However, for patients who were readmitted following ALIFs, the
164
readmission actually increased the average 90-day episode cost by 65-67%. Previously, Jain et al
165
found that while the overall readmission/revision rate for posterior lumbar interbody fusions
166
(PLIFs) was approximately 2.1-2.7%, a readmission would account for 25%-54% of the total 90-
167
day reimbursement20. With such an influential effect on total cost, reducing readmissions via
168
quality improvement protocols will be an important target for increasing value in care following
169
ALIFs.
170
Although this description of the 90-day cost distribution for anterior lumbar interbody
171
fusion can inform bundled payment structure, several limitations need to be taken into account
172
when translating this analysis to policy. First, these findings are limited in generalizability due
173
to the payers studied and relatively small sample size. Second, these aggregate data reflect the
174
average of all patients, but “outlier” patients or individuals with comorbidities will be present in
175
practice, potentially resulting in varied cost distributions that will necessitate risk adjustment in
176
bundled payments. Third, our analysis depended on administrative claims data, which can be
177
subject to inaccuracies from non-uniform coding practices across or even within facilities.
178
Additionally, while these findings identify potential targets for quality improvement and
179
subsequent cost reduction, evaluation of cost-effectiveness strategies and long-term outcomes is
180
beyond the scope of this study. We also did not analyze risk factors for readmissions, as these
181
analyses have already been performed previously using far more granular clinical data than that
182
provided by an administrative dataset. Patients who had incomplete follow-up were largely
183
individuals who had either switched their insurance plans (i.e. moved from Humana to another
184
payor and/or changed from Medicare Advantage to traditional Medicare) or had died during the
185
90-day post-operative period. When deriving target prices for bundled payment models,
186
insurance companies will actually exclude patients who died, since they are likely to skew the
187
actual price for a normal single-level ALIF. Due to these reasons, we chose to adopt a similar
188
approach and excluded this cohort from analysis.
189
Despite these limitations, this is the first study describing the cost distribution associated
190
with the 90-day episode of care following a single-level anterior lumbar interbody fusion for
191
Medicare Advantage and commercial insurance enrollees. Facility costs were the major driver of
192
total reimbursement, while costs associated with post-acute care did not contribute greatly to the
193
total bill. However, for patients who were readmitted, the average total 90-day cost of care
194
increased significantly. Taken together, these findings identify reducing both facility expenses
195
and readmissions as key targets for reducing the cost of care for single-level anterior lumbar
196
interbody fusions.
197
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265 266
Figure Legend
267
Figure 1: Distribution of 90-day costs following a single-level ALIF in Medicare Advantage
268
beneficiaries.
269
Figure 2: Distribution of 90-day costs following a single-level ALIF in Commercial
270
beneficiaries.
Category Facility Surgeon Anesthesia Hospitalization & Services
Radiology
Office visits
Physical therapy/rehab
ED visits
Codes ICD-10-P-0SG00A0, ICD-10-P-0SG30A0, ICD-9-P8106 CPT-22558, CPT-22845, CPT-20931, CPT-20396, CPT-20937, CPT-20938, CPT-22851 CPT-00630, CPT-00670 CPT-99221 to CPT-99223, CPT-99231 to CPT99233, CPT-99252 to CPT-99255, CPT-99291 to CPT-99292 CPT-72080, CPT-72100, CPT-72100, CPT-72110, CPT-72100, CPT-72100, CPT-72110, CPT-72110, CPT-72114, CPT-72114, CPT-72120, CPT-72148, CPT-72148, CPT-72158, CPT-72158, CPT-72265 CPT-99202, CPT-99203, CPT-99204, CPT-99205, CPT-99211, CPT-99211, CPT-99212, CPT-99212, CPT-99213, CPT-99213, CPT-99214, CPT-99214, CPT-99215, CPT-99215, CPT-99242, CPT-99243, CPT-99244, CPT-99245 CPT-97001, CPT-97001, CPT-97002, CPT-97010, CPT-97010, CPT-97012, CPT-97014, CPT-97014, CPT-97016, CPT-97032, CPT-97032, CPT-97035, CPT-97035, CPT-97110, CPT-97110, CPT-97112, CPT-97112, CPT-97113, CPT-97113, CPT-97116, CPT-97116, CPT-97140, CPT-97140, CPT-97150, CPT-97162, CPT-97530, CPT-97530, CPT-97001, CPT-97001, CPT-97003, CPT-97016, CPT-97110, CPT-97116, CPT-97150, CPT-97530, CPT-99305, CPT-99306, CPT-99307, CPT-99308, CPT-99309, CPT-99310, CPT-99316, DRG-2008-945 CPT-99281 to CPT-99285
Table 1: Distribution of 90-day costs for patients undergoing single-level ALIF in Medicare Advantage and Commercial beneficiaries. Category Facility Surgeon Anesthesia Hospitalization & Services Radiology Office Visits Physical Therapy/Rehab Emergency Department Visits Readmissions Total Average 90-day Reimbursement/patient
Medicare Advantage (N=244) $4,770,688 (76.4%) $715,530 (11.5%) $104,676 (1.7%) $53,700 (0.9%) $21,828 (0.3%) $41,813 (0.7%) $36,185 (0.6%) $33,660 (0.5%) $460,559 (7.4%) $6,238,639 (100%) $25,568/patient
Commercial (N=121) $4,635,994 (74.0%) $589,633 (9.4%) $211,024 (3.4%) $17,838 (0.3%) $28,985 (0.5%) $14,634 (0.2%) $34,410 (0.5%) $30,508 (0.5%) $697,741 (11.1%) $6,260,767 $51,741/patient
Abbreviations ALIF: Anterior Lumbar Interbody Fusion CPT: Current Procedural Terminology HAC: Humana Administrative Claims MA: Medicare Advantage
CRediT author statement Azeem Tarique Malik: Conceptualization, Methodology, Software, Data curation, WritingOriginal draft preparation. Selina Deiparine: Writing-Original draft preparation. Safdar Khan: Writing-Reviewing and Editing. Jeffery Kim: Writing-Reviewing and Editing. Elizabeth Yu: Supervision, Writing-Reviewing and Editing.
S1878-8750(19)33149-3
DOI:
https://doi.org/10.1016/j.wneu.2019.12.117
Reference:
WNEU 13964
To appear in:
World Neurosurgery
Received Date: 18 November 2019 Revised Date:
18 December 2019
Accepted Date: 19 December 2019
Please cite this article as: Malik AT, Deiparine S, Khan SN, Kim J, Yu E, Costs associated with a 90-day Episode of Care following a Single-Level Anterior Lumbar Interbody Fusion (ALIF), World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.117. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Costs associated with a 90-day Episode of Care following a Single-Level Anterior Lumbar Interbody Fusion (ALIF) Azeem Tariq Malik, MBBS, Selina Deiparine, BA, Safdar N Khan, MD, Jeffery Kim, MD, Elizabeth Yu, MD Department of Orthopaedics, The Ohio State University Wexner Medical Center Short Title: 90-Day Bundle for ALIF Corresponding Author: Elizabeth Yu, MD Associate Professor Fellowship Director, Orthopaedic Spine Department of Orthopaedics Division of Spine Surgery The Ohio State University Wexner Medical Center Tel: 614-293-0706 Fax: 614-293-6250 Email: [email protected]
Keywords: anterior lumbar interbody fusion; costs; bundled payment; Humana; Medicare advantage; Commercial; ALIF
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Abstract Introduction Anterior Lumbar Interbody Fusion (ALIF) is a commonly performed surgical procedure for the management of degenerative lumbar spine pathologies. Despite an increasing number of ALIFs being performed nationally, no study has evaluated the costs associated with the 90-day episode of care following the surgery. Materials and Methods: The 2007-2016 Humana Administrative Claims (HAC) dataset, a national database of Commercial and Medicare Advantage (MA) beneficiaries, was queried using Current Procedural Terminology code 22558 for patients undergoing single-level ALIFs. Ninety-day costs were defined on the basis of the following categories (facility, surgeon, anesthesia, other hospitalization costs and services, radiology, office visits, physical therapy/rehab, emergency department visits and readmissions). Results: A total of 365 ALIFs (MA=244; Commercial=121) were included in the analysis. The average 90-day cost of single-level ALIF was $25,568 and $51,741 for MA and Commercial enrollees respectively. The major proportion of 90-day costs was attributable to facility reimbursements (74%-76%), followed by surgeon costs (9%-11%). Post-acute care (office visits and physical therapy/rehab) were not major drivers of 90-day costs, consisting of only 0.7%-1.3% of the total 90-day reimbursement. Among patients who got readmitted, the cost of the readmission increased the average 90-day cost by 65%-66%. Conclusions: Facility costs were the major driver of a stipulated 90-day reimbursement for patients undergoing a single-level ALIF. Health-policy makers and providers can utilize this data to better understand the distribution of costs in a stipulated bundled-payment model for ALIFs, and allow them to identify areas where cost-reduction strategies can be carried out.
41 42
Introduction At present, the per capita spending of the U.S. healthcare system far exceeds that of any
43
other country in the world1. The lack of a cost-saving incentive in the current fee-for-service
44
model (i.e. providers are reimbursed individually by each service supplied), compounded with
45
continuously rising prices2 are contributing to a high economic burden. This economic burden
46
has precipitated health-policy makers to focus around driving value, rather than volume, in
47
healthcare. In order to curtail costs associated with expensive surgical conditions particularly,
48
health-policy makers have increasing looked at alternative payment models, such as episodic
49
bundling, to introduce the concept of financial risk-sharing, in order to maintain and/or increase
50
quality while reducing costs3-7. Episode-based bundling is essentially based on the principle of
51
distributing payments, out of a single pre-defined “bundled target payment”, to all service
52
providers (hospitals, physicians, and post-acute care) associated with an “episode of care”8,9.
53
While the duration of the episode-of-care can vary anywhere between inpatient-only to up to 90-
54
days, most bundled payments for orthopaedic surgical conditions (i.e. hip fractures10, spinal
55
fusions11,12 and total joint arthroplasties13,14), largely revolve around a 90-day bundled period
56
which begins on the day of surgery and ends at the 90-day follow-up time.
57
More than 400,000 spinal fusions are performed in the United States alone every year,
58
generating an annual cost-burden of more than $33 billion15,16. Furthermore, given that lumbar
59
fusions are among the top three conditions of Medicare expenditure17, these surgeries offer a lot
60
of opportunity for implementing value through bundled payments. While posterior lumbar
61
fusions still remains the most common approach for performing lumbar fusions, due to
62
expanding indications and technical improvements, there has been a relative rise in the use of
63
anterior lumbar fusions for the management of degenerative spinal pathology18. Despite the
64
increase in the number of anterior lumbar fusions performed and the broader focus on value, no
65
study to date has evaluated the distribution of costs associated with a 90-day episode of care
66
following a single-level anterior lumbar interbody fusion (ALIF). An understanding of the costs
67
associated with this specific procedure would be essential for identifying potential areas for cost
68
reduction and optimizing value through bundled payment models. In the light of the latter
69
observations, we sought to utilize a national insurance claims dataset to understand the
70
distribution of 90-day costs following a single-level ALIF for degenerative spinal pathology.
71 72
Methods
73
Database and Patient Selection
74
This was a retrospective study performed using the Humana Administrative Claims
75
(HAC) database. The HAC database is a comprehensive source of insurance claims from over 20
76
million Commercially-insured and Medicare Advantage (MA) beneficiaries across the nation.
77
The data is stored on a super-computer, and is made available to users (on a subscription basis)
78
through the PearlDiver research software. The claims can be queried using a unique coding
79
language that utilizes combinations of International Classification of Diseases 9th/10th Edition
80
(ICD-9/ICD-10) diagnosis codes, procedure codes and Current Procedural Terminology (CPT)
81
codes. All data retrieved from the HAC database is presented in a de-identified format, and the
82
study, therefore, was exempt from Institutional Review Board (IRB) approval. Further details
83
regarding the PearlDiver research software and the HAC database can be found on the official
84
website (www.pearldiverinc.com).
85 86
The 2007-2016 HAC data files were queried using CPT codes 22558 to identify patients undergoing single-level ALIFs. Patients undergoing multi-level fusions, adjunct posterior
87
fusion/instrumentation, fusion for deformity/trauma/malignancy and those with missing data
88
with excluded from the study. The before-mentioned exclusion criteria were applied to ensure
89
that only patients undergoing single-level ALIFs for degenerative spinal pathology were
90
included in the final cohort. Patients who had incomplete follow-up during the 90-day post-
91
operative period, or those who died during the 90-day post-operative period were also excluded.
92
Since Medicare Advantage and Commercial plans have starkly different reimbursement
93
rates/policies, the study cohort was divided into two cohorts (Medicare Advantage or
94
Commercially-insured) and analyzed separately
95
Ninety-Day Cost Categories
96
The terms “costs”, “payments” and/or “reimbursements”, used interchangeably
97
throughout the manuscript, refer to the actual payments made by the insurance company to
98
service providers, and are not “charges” (payments claimed by hospitals). Ninety-day costs were
99
defined on the basis of the following categories 1) facility costs – which included payments
100
made to the hospital, as well as implant costs, 2) surgeon (payments made to the operating
101
physician), 3) anesthesia (payments made to the anesthesiologist), 4) Other hospitalization
102
costs/services (costs attributable to ancillary investigations, such as labs etc.), 5) radiology, 6)
103
office visits, 7) physical therapy/rehab (included both skilled nursing facility, outpatient
104
rehabilitation and inpatient rehabilitation), 8) emergency department (ED) visits and 9)
105
readmissions. A complete list of codes used to retrieve the before-mentioned categories can be
106
found in the Appendix. Descriptive analysis was used to report the average cost/reimbursement
107
for each category, as well as the entire 90-day episode of care, for each patient.
108
109 110
Results Following application of inclusion/exclusion criteria, a total of 365 patients undergoing a
111
single-level ALIF for degenerative spinal pathology were included in the study. Out of the 365
112
ALIFs, 244 were performed in Medicare Advantage beneficiaries and 121 were performed in
113
Commercial beneficiaries. The average 90-day cost of single-level ALIF was $25,568 and
114
$51,741 for Medicare Advantage and Commercial beneficiaries respectively.
115
Medicare Advantage Beneficiaries
116
A detailed description showing the average cost/category for Medicare Advantage
117
beneficiaries can be seen in Table 1 and Figure 1. The major proportion of 90-day costs was
118
attributable to facility reimbursements (76.4%), followed by surgeon costs (11.5%). Costs
119
attributable to anesthesia and other hospitalizations services constituted 1.7% and 0.9% of the
120
total 90-day cost, respectively. Post-acute care (office visits and physical therapy/rehab) were not
121
major drivers of 90-day costs, consisting of only 1.3% of the total 90-day costs. Even though
122
readmissions themselves contributed around 7% of the total 90-day cost, among patients who got
123
readmitted (N=27; 11.1%), the average cost of the readmission ($17,058) increased the average
124
90-day cost by 66.7%.
125
Commercial-only Beneficiaries
126
A detailed description showing the average cost/category for Medicare Advantage
127
beneficiaries can be seen in Table 1 and Figure 2. Facility costs were responsible for around 74%
128
of the total 90-day reimbursements, followed by surgeon costs (9.4%). Costs attributable to
129
anesthesia and other hospitalizations services constituted 3.4% and 0.3% of the total 90-day cost,
130
respectively. Post-acute care (office visits and physical therapy/rehab) constituted only 0.7% of
131
the total 90-day costs. Even though readmissions themselves contributed around 11% of the total
132
90-day cost, among patients who got readmitted (N=7; 5.8%), the average cost of the
133
readmission increased the average 90-day cost by 65.5%.
134 135
Discussion
136
Although the United States spends more per capita on health delivery/care than any other
137
nation, the country’s system still ranks last, among industrialized nations, on overall performance
138
and quality of healthcare19. Alternative payment models such as episodic bundling represent a
139
potential solution to the rising costs of care and high economic burden of the current health care
140
system. Maximizing value in such bundled models will require an understanding of the
141
distribution of costs associated with care for specific procedures, which will aid providers and
142
health policy-makers in identifying appropriate targets for quality improvement. As evidenced in
143
our study, in a stipulated 90-day bundled payment model for single-level ALIFs, facility costs
144
are responsible for the greatest share of (74.0%-76.4%) of reimbursements. This is consistent
145
with previous analyses, which have shown that facility costs such as surgical implants, length of
146
inpatient stay, and operating room time contribute approximately 73%-92% of the total 90-day
147
costs20,21. Given the latter findings, optimizing facility costs through either improving/shortening
148
inpatient length of stay or aggressive contracting/value-based purchasing of implants, can be an
149
effective way of bringing down costs across the entire episode of care. Another way of reducing
150
facility costs is by transitioning surgery to outpatient/ambulatory surgery centers for a carefully
151
selected low-acuity patient population. With the advent of minimally invasive technology that
152
allows minimal exposure and quick recovery, it is likely that outpatient spinal fusions become
153
readily prevalent in the upcoming decade.
154
Post-acute services (office visits and physical therapy/rehabilitation services) did not
155
contribute greatly to the total cost of the 90-day episode, consisting of 0.7%-1.3% of the total
156
reimbursement. While post-acute costs have been previously found to comprise approximately
157
36-38% of bundled costs for total joint arthroplasty22,23, they do not appear to constitute a
158
significant proportion of 90-day costs for spinal fusions. This findings highlights the importance
159
of focusing on optimizing facility costs to bring about value in patients, rather than simply
160
resorting to increasing the proportion of home discharges. For commercially insured patients,
161
readmission-related reimbursements were responsible for second largest share of total cost
162
(11.1%), while such payments comprised the third largest share of the 90-day total for Medicare
163
Advantage enrollees (7.4%). However, for patients who were readmitted following ALIFs, the
164
readmission actually increased the average 90-day episode cost by 65-67%. Previously, Jain et al
165
found that while the overall readmission/revision rate for posterior lumbar interbody fusions
166
(PLIFs) was approximately 2.1-2.7%, a readmission would account for 25%-54% of the total 90-
167
day reimbursement20. With such an influential effect on total cost, reducing readmissions via
168
quality improvement protocols will be an important target for increasing value in care following
169
ALIFs.
170
Although this description of the 90-day cost distribution for anterior lumbar interbody
171
fusion can inform bundled payment structure, several limitations need to be taken into account
172
when translating this analysis to policy. First, these findings are limited in generalizability due
173
to the payers studied and relatively small sample size. Second, these aggregate data reflect the
174
average of all patients, but “outlier” patients or individuals with comorbidities will be present in
175
practice, potentially resulting in varied cost distributions that will necessitate risk adjustment in
176
bundled payments. Third, our analysis depended on administrative claims data, which can be
177
subject to inaccuracies from non-uniform coding practices across or even within facilities.
178
Additionally, while these findings identify potential targets for quality improvement and
179
subsequent cost reduction, evaluation of cost-effectiveness strategies and long-term outcomes is
180
beyond the scope of this study. We also did not analyze risk factors for readmissions, as these
181
analyses have already been performed previously using far more granular clinical data than that
182
provided by an administrative dataset. Patients who had incomplete follow-up were largely
183
individuals who had either switched their insurance plans (i.e. moved from Humana to another
184
payor and/or changed from Medicare Advantage to traditional Medicare) or had died during the
185
90-day post-operative period. When deriving target prices for bundled payment models,
186
insurance companies will actually exclude patients who died, since they are likely to skew the
187
actual price for a normal single-level ALIF. Due to these reasons, we chose to adopt a similar
188
approach and excluded this cohort from analysis.
189
Despite these limitations, this is the first study describing the cost distribution associated
190
with the 90-day episode of care following a single-level anterior lumbar interbody fusion for
191
Medicare Advantage and commercial insurance enrollees. Facility costs were the major driver of
192
total reimbursement, while costs associated with post-acute care did not contribute greatly to the
193
total bill. However, for patients who were readmitted, the average total 90-day cost of care
194
increased significantly. Taken together, these findings identify reducing both facility expenses
195
and readmissions as key targets for reducing the cost of care for single-level anterior lumbar
196
interbody fusions.
197
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198
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265 266
Figure Legend
267
Figure 1: Distribution of 90-day costs following a single-level ALIF in Medicare Advantage
268
beneficiaries.
269
Figure 2: Distribution of 90-day costs following a single-level ALIF in Commercial
270
beneficiaries.
Category Facility Surgeon Anesthesia Hospitalization & Services
Radiology
Office visits
Physical therapy/rehab
ED visits
Codes ICD-10-P-0SG00A0, ICD-10-P-0SG30A0, ICD-9-P8106 CPT-22558, CPT-22845, CPT-20931, CPT-20396, CPT-20937, CPT-20938, CPT-22851 CPT-00630, CPT-00670 CPT-99221 to CPT-99223, CPT-99231 to CPT99233, CPT-99252 to CPT-99255, CPT-99291 to CPT-99292 CPT-72080, CPT-72100, CPT-72100, CPT-72110, CPT-72100, CPT-72100, CPT-72110, CPT-72110, CPT-72114, CPT-72114, CPT-72120, CPT-72148, CPT-72148, CPT-72158, CPT-72158, CPT-72265 CPT-99202, CPT-99203, CPT-99204, CPT-99205, CPT-99211, CPT-99211, CPT-99212, CPT-99212, CPT-99213, CPT-99213, CPT-99214, CPT-99214, CPT-99215, CPT-99215, CPT-99242, CPT-99243, CPT-99244, CPT-99245 CPT-97001, CPT-97001, CPT-97002, CPT-97010, CPT-97010, CPT-97012, CPT-97014, CPT-97014, CPT-97016, CPT-97032, CPT-97032, CPT-97035, CPT-97035, CPT-97110, CPT-97110, CPT-97112, CPT-97112, CPT-97113, CPT-97113, CPT-97116, CPT-97116, CPT-97140, CPT-97140, CPT-97150, CPT-97162, CPT-97530, CPT-97530, CPT-97001, CPT-97001, CPT-97003, CPT-97016, CPT-97110, CPT-97116, CPT-97150, CPT-97530, CPT-99305, CPT-99306, CPT-99307, CPT-99308, CPT-99309, CPT-99310, CPT-99316, DRG-2008-945 CPT-99281 to CPT-99285
Table 1: Distribution of 90-day costs for patients undergoing single-level ALIF in Medicare Advantage and Commercial beneficiaries. Category Facility Surgeon Anesthesia Hospitalization & Services Radiology Office Visits Physical Therapy/Rehab Emergency Department Visits Readmissions Total Average 90-day Reimbursement/patient
Medicare Advantage (N=244) $4,770,688 (76.4%) $715,530 (11.5%) $104,676 (1.7%) $53,700 (0.9%) $21,828 (0.3%) $41,813 (0.7%) $36,185 (0.6%) $33,660 (0.5%) $460,559 (7.4%) $6,238,639 (100%) $25,568/patient
Commercial (N=121) $4,635,994 (74.0%) $589,633 (9.4%) $211,024 (3.4%) $17,838 (0.3%) $28,985 (0.5%) $14,634 (0.2%) $34,410 (0.5%) $30,508 (0.5%) $697,741 (11.1%) $6,260,767 $51,741/patient
Abbreviations ALIF: Anterior Lumbar Interbody Fusion CPT: Current Procedural Terminology HAC: Humana Administrative Claims MA: Medicare Advantage
CRediT author statement Azeem Tarique Malik: Conceptualization, Methodology, Software, Data curation, WritingOriginal draft preparation. Selina Deiparine: Writing-Original draft preparation. Safdar Khan: Writing-Reviewing and Editing. Jeffery Kim: Writing-Reviewing and Editing. Elizabeth Yu: Supervision, Writing-Reviewing and Editing.