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Impact of a Bundled Payment System on Resource Utilization During Spine Surgery

James M. Mok, MD,1 Maximilian Martinez, MS,2 Harvey E. Smith, MD,3 Daniel M. Sciubba, MD,4 Peter G. Passias, MD,5 Andrew Schoenfeld, MD, MSc,6 Robert E. Isaacs, MD,7 Alexander R. Vaccaro, MD, PhD,8 Kris E. Radcliff, MD,9 Association for Collaborative Spine Research Investigators

1Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL, 2Rutgers University - New Jersey Medical School, Newark, NJ, 3Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 4Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, 5Division of Spinal Surgery, New York University School of Medicine, Westbury, NY, 6Department of Orthopedics, Brigham and Women's Hospital, Boston, MA, 7Division of Neurosurgery, Duke University, Durham, NC 8Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, Philadelphia, PA, 9Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, Egg Harbor Township, NJ



In a bundled payment system, a single payment covers all costs associated with a single episode of care. Spine surgery may be well suited for bundled payments because of clearly defined episodes of care, but the impact on current practice has not been studied. We sought to examine how a theoretical bundled payment strategy with financial disincentives to resource utilization would impact practice patterns.


A multiple-choice survey was administered to spine surgeons describing eight clinical scenarios. Respondents were asked about their current practice, and then their practice in a hypothetical bundled payment system. Respondents could choose from multiple types of implants, bone grafts, and other resources utilized at the surgeon's discretion.


Forty-three respondents completed the survey. Within each scenario, 24%-49% of respondents changed at least one aspect of management. The proportion of cases performed without implants was unchanged for four scenarios and increased in four by an average of 8%. Use of autologous iliac crest bone graft increased across all scenarios by an average of 18%. Use of neuromonitoring decreased in all scenarios by an average of 21%. Differences in costs were not statistically significant. 


Financial disincentives to resource utilization may result in some changes to surgeons' practices but these appear limited to items with less clear benefits to patients. Choices of implants, which account for the majority of intra-operative costs, did not change meaningfully. A bundling strategy targeting peri-operative costs solely related to surgical practice may not yield substantive savings while rationing potentially beneficial treatments to patient care. Level of Evidence: 5.

Patient Protection and Affordable Care Act, Spine surgery, bundled payments, health care reform, Cost, resource utilization
Volume 10 Article 19