Sigurd Berven, MD, professor of orthopedic surgery at the University of California San Francisco gave a presentation titled "Determining Value Through Identification of Independent Predictors of the Cost for Spine Surgery," at the North American Spine Society Annual Meeting in October.
Providers are now entering into new payment models with payers, such as accountable care organizations and bundled payments, which require physicians to take on risk. If you are going to accept risk, it's important to identify cost factors. Examine indiscriminant and independent variables that surgeons can influence for cost-saving or quality-improving opportunities.
"Expenditures are high and characterized by significant variability. There is very little transparency in the components of direct cost for the management of spinal disorders, be it operative care or nonoperative care. Identifying cost contributors that are independent predictors of total cost, and that have the highest variability may offer guidance in cost-saving strategies," said Dr. Berven.
When there is variability, there is opportunity for change. Total expenditures for spine care have increased disproportionately to other musculoskeletal interventions over the past decade, and the cost has increased without a proportionate improvement in the rates of solid fusions and clinical outcomes, Dr. Berven said, based on recent reports.
The same trend is also true for non-operative care; there has been a two-fold increase in non-operative care expense from 2002 to 2008, according to a 2012 report published in Spine.
Dr. Berven broke down the costs for a single episode of care, focusing on spine surgery. For lumbar discectomy, he cited studies showing there is more than a two-fold variation in the direct costs — ranging from $3,710 to $8,132 — and 10-fold variation for a single level fusion from case to case — ranging from $8,286 to $73,827.
The main drivers of this variation are:
• High variability in implant costs, which is related to the surgical strategy
• Comorbidities
• Length of stay
• Patient transfers to the ICU
At UCSF, Dr. Berven and his colleagues examined 535 patients undergoing a primary single level lumbar fusion. Costs were broken down into services, room and care, pharmacy and supplies. The vast majority of the costs were between supplies and services, with supplies being nearly half of the total costs. Implants included bone graft materials and operating room supplies. Specifically, cases done with an interbody cage were an independent predictor of higher cost.
New technologies that add cost but don't necessarily clearly add a lot of benefit
"Ultimately any time we think of a new device, new technology and new technique, we need to think about what value we are really getting for that new device, instrumentation or technique," said Dr. Berven.
The strategy surgeons used during surgery also had an impact on the cost of care. Cell saver and single-level fusion was done in 20 percent of the cases, but only 2 percent of cases received anything back from cell saver. Surgeons used nerve monitoring only half of the time.
"That's an area where there's a lot of variability and not much consensus so maybe there's an opportunity for cost-savings there," said Dr. Berven. "I'm very bullish on nerve monitoring for deformity, but I think for single-level fusions it might not be a necessary service."
Pharmacy costs were often higher in patients with comorbidities. The researchers found the use of interbody cages and BMP, as well as performing circumferential procedures were higher costs than other implants and techniques. "The question becomes, did that add value," said Dr. Berven. "Did the addition of BMP add value because if it didn't add value then maybe there is some room to change."
Finally, they found patients who had their procedures in an orthopedics specialty unit had a shorter length of stay and fewer transfers to the ICU, contributing to lower costs. He also touched on improving readmission rates and how reducing them could contribute to the overall value of spine care.
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