Abstract
Study design
Retrospective multicenter cost analysis.
Objective
To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA.
Summary of background data
Previous studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.
Methods
From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (> 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost < MA.
Results
Administrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost < MA. There was significant variation across the four centers in both iEOC cost ($56,788–$78,878, p < 0.0001) and reimbursement ($40,623–$91,351, p < 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs < MA (67.2% vs 8.9%, p < 0.0001). Recursive partitioning (r2 = 0.309) identified rhBMP-2 use of < 24 mg, sagittal plane deformity, a combined anterior/posterior approach, and an SF36-MCS < 39 as predictive for iEOC cost < MA. Performing an anterior/posterior approach reimburses between 14.7% and 121.1% more (2.2-fold) than posterior-only approach. This change in DRG allows iEOC cost to be more likely below the MA threshold.
Conclusion
There is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.
Level of evidence
III.
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Funding
This study was funded by the International Spine Study Group Foundation.
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JLG, BL: conception or design of the work, JLG, RAH, SY, SDG, DLB, JSS, CIS, PGP, VL, CPA, RSB: acquisition of data, BL: analysis of data, JLG, LYC, RAH, SY, SDG, DLB, JSS, CIS, PGP, VL, CPA, RSB: interpretation of data, JLG: drafted the work, revised it critically, JLG, BL, LYC, RAH, SY, SDG, DLB, JSS, CIS, PGP, VL, CPA, RSB: approved the version to be published; and agree to be accountable for all aspects of the work.
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CPA receives royalties from Stryker, Biomet, DePuy, Nuvasive, Next Orthosurgical, K2M, Medicrea; consulting fees from DePuy Synthes, Medtronic, Medicrea, K2M. RSB receives royalties from K2M/Stryker; consulting fees from K2M Stryker, Mirus; grants to institution from DePuy Synthes, Medtronic, Globus, K2M Stryker, Nuvasive. DLB receives royalties from DePuy, Progenerative Medical; consulting fees from DePuy Spine; Board member International Spine Study Group, Scoliosis Research Society; Research Support to institution from DePuy Spine, Bioventus. Pfizer, Progenerative Medical. LYC receives consulting fees National Spine Health Foundation; member, Editorial Advisory Board, Spine Deformity, The Spine Journal and Spine; member University of Louisville IRB. Institution received research funds from OREF, NIH, ISSG, SRS, TSRH, Pfizer, Lifesciences Corporation, IntelliRod, Cerapedics, Medtronic, Empirical Spine and NeuroPoint Alliance. SDG receives royalties from Medtronic, Spinger; consulting Fees Medtronic K2m/Stryker; Institution received research funds from OREF, NIH, ISSG, SRS, TSRH, Pfizer, Lifesciences Corporation, IntelliRod, Cerapedics, Medtronic, Empirical Spine and NeuroPoint Alliance. VL receives royalties from Nuvasive; has stock ownership from Nemaris; consulting fees from Globus, Speakers Bureau for Permanente Medical Group, DePuy Synthes Spine, AO Spine, K2M, Implanet. BL receives consulting fees International Spine Study Group. PGP receives consulting fees from Medicrea, Spine Wave, Speaker’s fees from Zimmer, Globus, Research support to institution from Cervical Spine Research. CIS receives royalties from Medtronic, Nuvasive, Zimmer/Biomet; has Stock ownership NuVasive, receives consulting fees from Medtronic, SI Bone; Board member Scoliosis Research Society, Anerican Association of Neurological Surgeons; grant to institution from the Deparment of Defense. JSS receives royalties from Zimmer Biomet, Nuvasive; has Stock ownership Alphatec; receives consulting fees from Zimmer Biomet; Nuvasive, Cerapedics, Allosource; research grant to institution DePuy Synthes/ISSG; Fellowship support to institution NREF, AO Spine.
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This article does not contain any studies with human participants performed by any of the authors. This study was reviewed by the University of Louisville Institutional Review Board and determined to be Not Human Subjects Research.
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Gum, J.L., Line, B., Carreon, L.Y. et al. Reaching the medicare allowable threshold in adult spinal deformity surgery: multicenter cost analysis comparing actual direct hospital costs versus what the government will pay. Spine Deform 10, 425–431 (2022). https://doi.org/10.1007/s43390-021-00405-4
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DOI: https://doi.org/10.1007/s43390-021-00405-4