160. Fusion for fracture has no place in a lumbar fusion bundled payment model: an analysis of Medicare beneficiaries

Abstract

BACKGROUND CONTEXT The current bundled payment model for lumbar fusions combines all fusions, irrespective of indication/cause/diagnosis, into one single broad group for defining prospective payments. Due to this grouping methodology, fracture get clubbed into the same group as elective degenerative cases, despite the former having a possibly different peri- and postoperative resource utilization. PURPOSE The current study aims to evaluate differences in 90-day outcomes and readmissions following lumbar fusions being carried out for fractures, versus those being done for degenerative pathologies STUDY DESIGN/SETTING Retrospective review of 2008-2014 Medicare 100% Standard Analytical Files (SAF100) database. PATIENT SAMPLE The 2008-2014 Medicare 100% Standard Analytical Files (SAF100) were used to identify patients undergoing lumbar fusions under diagnosis-related group (DRG) 459 and 460. A DRG-based approach was used to identify patients as current bundled payment models use DRGs to identify/trigger episodes of care for spinal fusions. International Classification of Diseases 9th (ICD-9) diagnosis codes were used to identify patients undergoing fusion for a fracture. OUTCOME MEASURES Ninety-day complications and readmissions. METHODS Multivariate logistic regression analyses were used to assess for differences in 90-day complications and readmissions between fracture patients vs degenerative lumbar fusions, while controlling for baseline demographic and clinical characteristics (including surgical approach, length of fusion, adjunct laminectomy/discectomy, use of bone graft etc.). RESULTS A total of 280,893 patients were included – out of which 1.8% (N=5,279) underwent fusion for a fracture. After adjusting for covariates, patients undergoing fusion for a fracture vs degenerative pathology, had significantly higher rates of 90-day wound complications (11.4% vs 4.2%, OR 2.00 [95% CI 1.82-2.20]; p CONCLUSIONS The current bundled payment model for lumbar fusions fails to risk-adjust payments, based on indication of surgery (fracture vs degenerative pathology), despite the fact that fracture cases tend to have higher rates of complications and readmissions. The lack of risk-adjustment may lead to a financial disincentive in taking care of fracture patients, thereby introducing barriers to access of care for this vulnerable patient population. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.