Spinal surgery is associated with high costs as well as significant variation in approach and care. There have been substantial increases in the utilization of complex spinal surgery in the last 20 years. Annual expenditures in the United States currently average $110 billion in direct costs. By 2025, total health expenditures are expected to average $5.3 trillion, or close to 20% of the gross domestic product of the United States.
With high resource utilization and often uncertain outcomes, spinal surgery has been heavily scrutinized by payers and hospital systems, with efforts to reduce costs and standardize surgical approach and care pathways. Furthermore, health care reform has developed into an environment of decreasing reimbursements, increasing payer denials, and profiling hospitals and physicians on the utilization and quality of care.
It is incumbent upon surgeons to ensure that efforts be made to reduce cost without compromising patient-reported outcomes. Without innovation, or significant downsizing, the current trajectory of spine surgery expenditures is not sustainable.
Cost driver
Cost driver’ as defined in this study is the factor that results in a change in the cost of a procedure cost while ‘cost’ is represented by the actual cost for the procedure or what the medical system was reimbursed for the procedure. A surgeon’s understanding of the cost and cost drivers in his/her practice allows for identification of variances in cost which ultimately allow for development of strategies that could allow for cost reduction in the current climate of increasing health care expenditure.
What are the cost drivers in spine surgery?
Reported studies mention the cost drivers for a single level lumbar fusion including single level posterior fusion, lateral fusion, TLIF, and ALIF. 44% of total cost was for surgical supplies, 38% for services, 14% for room and care, and 4% for pharmacy. Their major drivers of cost included surgical approach, implants, operating room time, and length of hospital stay. The use of an interbody device represented a high portion of the direct cost for instrumented fusions.
Overall major costs in lumbar fusion are driven by facility charges and cost of supplies and implants. Surgeon fees and imaging account for a small percentage of total cost.
Unplanned postoperative readmission resulted in the highest cost to postoperative spending and second highest to overall costs.
Patient Related Cost Drivers
Several studies assessed the role of patient comorbidities on cost related to spine fusion. Most studies demonstrate that higher BMI, age, diabetes, adverse events, and higher severity of index score all resulted in higher cost for patients undergoing spine fusion.
Morbid obesity resulted in a 10 times higher rate of wound complication and $9,078 increase in overall cost.
Some studies report that a history of more than 1 admission in the prior year, lumbar fusion of 4 or more levels, and surgery duration greater than 5 hours were predictors of increased hospital charges.
Infections following spine fusion surgery can impose significant financial impact on the health care system. Several studies evaluated the cost burden of post-operative wound infections and presence of systemic infections with spine surgery. Adjusted for inflation, wound infections were associated with higher cost of an average $12,619 more that those without infection. Interestingly, patients with HCV undergoing lumbar fusion had higher incidence and odds of requiring a blood transfusion, developing pneumonia, respiratory failure, UTIs, wound infections, and cerebrovascular accidents.
Cost Cutting Strategies in Spine Surgery
1.Analyse costs
Understand where the big cost drivers are for spine care so you can locate opportunities for cost reduction. So analysing data is crucial. Spine surgeons should be part of this process because if they don’t know what the procedure costs, they can’t find areas for savings.
2.Surgeon Awareness of Implants and Biologics Costs
Within our technology-driven field, a major cost driver for spinal surgery continues to be innovative implants and biologics used in complex spinal operations. Several studies have demonstrated that increased surgeon awareness of implant costs results in decreased implant costs.
After providing cost education to surgeons, one prospective study demonstrated cost reductions for ACDF implants.
Intraoperative waste in spinal surgery was prospectively measured at a single-institution, before and after surgeon education, and was shown to decrease from 20.2% of cases to 10.3% of cases, resulting in a cost savings of over $70,000 per year. Surgeons should be knowledgeable not only about the instruments they use, but also about their cost. Awareness of implant cost is thus essential in the pursuit of cost reduction.
3.Transparency and Vendor Pricing and RenegotiatIing instrument and implant costs
The cost of spinal fusion implants varies widely between different medical systems, with little transparency. Hospital systems have increasingly made efforts to aggressively negotiate lower implant prices, and limit the number of vendors to allow bulk-purchasing discounts. In one study, University Health System Consortium implant pricing benchmarks and national pricing data were used to create a reference cost for each implant. Any vendor that matched it pricing to the reference cost could make their products available to the surgeons.
In some spine centres, transition from a multivendor to a dual-vendor strategy was associated with a 24% reduction in annual costs for nonspecialized devices. Simultaneous transition to the initial capitated pricing model for specialty implants was associated with a 35% reduction in annual costs for those products.
Physician preferences for items such as spinal implants are based on a variety of considerations, including relationships with vendor sales representatives, sales and training support, personal experience with a device or brand, and cost and other financial considerations. Nevertheless, factors, such as patient outcomes, implant longevity, ease of use, and implant design, are most important in shaping physician preferences for orthopaedic implants. Therefore, any initiative that curtails access to physician preference items has the possibility of affecting patient outcomes and should be evaluated not only on the economic merits of the program but also on its potential clinical impact.
Standardization of protocols and implants between surgeons may result in greater cost savings, without compromise of patient outcomes. This process must be delicately balanced with surgeon autonomy and comfort-level using various instrumentation.
4.Operating room efficiency
The combination of a dedicated surgical team, neuromonitoring, standard anaesthetic protocol, checklists, and splitting into procedural processes (“chunks”) have proven to make spine surgery more efficient and less costly. There have been improvements in operative time, surgical room times, average length of stay, and a reduced overall cost per encounter.
Equipment efficiency is one of the most important elements for making sure a case runs smoothly. Have the proper equipment available and make sure there is a replacement if necessary.
5.Ambulatory Care Centres
There has been significant interest in performing more surgery in ambulatory care centres as opposed to traditional hospitals. Much of the cost of spinal surgery is tied to hospital metrics such as length of stay and inpatient utilization of expensive resources.
As technology evolves more and more spine surgeries will be done as day surgeries. This change has been in response to decreasing invasiveness of surgery, patients’ desire to recuperate at home, and significant net reductions in cost, which is critical in this era of value-based care. However, it applies to a selected group of patients with careful selection criteria and strict postoperative protocols in place.
https://www.myspineworld.com/ambulatory-spine-surgery-no-more-a-myth/
6.Patient Selection and Complication Avoidance
While surgeons recognize the importance of patient selection for optimizing surgical outcome and reducing costs, it is often not ethical to deny a patient surgery based upon risk factors such as age and medical co-morbidities.
Several efforts have been published to develop more comprehensive preoperative evaluation protocols, including multi-disciplinary conferences and careful anaesthetic preparations prior to complex spine operations.
These team approaches to complex spine operations have been shown to reduce reoperation, wound infection, deep venous thromboembolism, and other perioperative complications. Spinal surgeons and insurance payers are increasingly focused on optimizing modifiable patient risk factors prior to surgery, such as smoking, osteoporotic bone density, and elevated haemoglobin A1C.
Patient education related to the perioperative risks associated with smoking, osteoporosis, and uncontrolled diabetes is important for both encouraging behaviour modification and acceptance of delay in surgery.
7.Artificial intelligence
Predictive analysis and machine learning have emerged as valuable tools for predicting patient outcomes based on pertinent feature characteristics variables . Developing patient-centred outcome prediction models, including those for patient-related outcome measures and length of stay, can contribute to improving society’s utilization of healthcare resources. In doing so, policymakers and clinicians could compare treatments across disciplines to determine how best to allocate budget resources among different approaches.
Many studies have already shown that certain characteristics are associated with a longer hospital stay following spinal surgery. A longer length of stay (LOS) was associated with an increase in operating time during adult spinal deformity surgery.
The authors of a multicentre study found that age, the number of levels fused, infection, and comorbidities are risk factors for a higher death rate.
Despite their ability to identify individuals likely to have a longer LOS, risk indicators cannot predict whether a patient will have a longer LOS. The use of machine learning and deep learning algorithms can enhance the knowledge provided by these studies and predict whether a particular patient will require a normal length of hospital stay or an extended hospital stay based on a wide range of clinicopathological characteristics.
In particular, these algorithms can be integrated into the hospital’s software environment, resulting in continuous monitoring of at-risk patients and the achievement of precision medicine goals.
https://www.myspineworld.com/artificial-intelligence-machine-learning-in-spine/
8.Enhanced Recovery after Surgery (ERAS) Protocols
Reduction in hospital length of stay would be expected to significantly reduce hospital costs associated with spinal fusion surgery. One of the underlying principles of ERAS protocols is standardizing the approach to pain control, education, and early mobilization after spinal surgery. Adherence to these standardized protocols is variable and therefore the results are not always associated with lowering hospital costs.
However, standardization of hospital peri-operative protocols has been associated with lower costs and improved outcomes for a number of surgical procedures. ERAS protocols for different types of spine surgery are an effective means of improving patient outcomes, ranging from improved postoperative pain to reduced length of stay without causing increased postoperative complications. This also indirectly reduces overall costs associated with spine surgery. Understanding that a shorter LOS is indicative of faster patient recovery, it’s important that providers are educated and made aware of the evidence-based effects of implementing a multidisciplinary, multimodal approach to patient care for spine surgery like ERAS.
https://www.myspineworld.com/eras-in-spine-fast-track-spine-surgery%ef%bf%bc/
Not every spine surgeon needs to be an economist or health policy analyst, however all spine surgeons can contribute to the definition of value in spine care through participation in pre-operative risk assessment, accurate and complete complication reporting, and patient reported outcomes measures.
Surgeons should go beyond participation in cost effective strategies and spearhead initiatives to reduce cost without compromising outcomes. It begins with education around the overall costs associated with spine instrumented surgery with a focus on identifying the cost drivers. This can be followed by creating an atmosphere of transparency as it relates to facility fees and implant cost.
Embracing what works and is valuable and discarding what is not effective or valuable is an easy concept to understand and an impossible one to argue with.