Elective Versus Nonelective Spinal Fusions: Surgical and Financial Outcomes in a Bundled Payment Reimbursement Model

Bundled payment for care improvement advanced (BPCIA) is a voluntary alternative payment model administered by the Centers for Medicare and Medicaid Services using value-based care to reduce costs by incentivizing care coordination and improved quality. We aimed to identify drivers of negative financial performance in BPCIA among patients undergoing spinal fusion surgery.

This is a single-institution retrospective review of patients enrolled in BPCIA undergoing spinal fusion with DRGs 453, 454, 455, 459, and 460 from 2018 to 2022. Univariate and multivariable logistic regression analyses were used to identify factors associated with negative financial performance and compare nonelective vs elective surgeries.

We identified 172 cases, of which 24% (n = 41) had negative financial performance and 9% (n = 16) were nonelective cases. Nonelective surgery (P < .001, odds ratios 19.81), greater levels instrumented (P < .001), and no anterior procedure (P = .001) were associated with negative financial performance. Surgical outcomes associated with negative financial performance and factors more common in nonelective cases respectively included higher hospital length of stay (P < .001, P = .005), nonhome discharge (P < .001, P < .001), 90-day hospital readmission (P < .001, P < .001), 90-day additional nonspine surgery (P = .01, P < .001), and less days at home of the 90 days (P < .001, P = .01). Nonelective surgeries had higher total spend (P = .01), readmission spend (P = .03), skilled nursing facility spend (P = .02), durable medical equipment spend (P = .003), and professional billing spend (P = .04) despite similar target pricing (P = .60), all of which resulted in greater financial loss compared with elective surgeries (P = .001).

Nonelective spinal surgery is an independent preoperative predictor of negative financial performance in BPCIA. Nonelective spinal surgeries are more likely than elective surgeries to have higher length of stay, nonhome discharge, 90-day hospital readmission, 90-day additional nonspine surgeries, and less time spent at home during the bundled period, all of which contribute to higher health care utilization. The Centers for Medicare and Medicaid Services should consider incorporating nonelective spine surgery into risk-adjustment models.