Spine surgeons, hospitals wary of CMS' proposed spinal fusion bundles

Spine

CMS is proposing a new payment model — called the Transforming Episode Accountability Model — that would bundle payments for spinal fusions, among other procedures, to acute care hospitals, but spine surgeons and the American Hospital Association are wary.

The AHA on June 10 expressed concerns about the model saying the proposed model is "proposing to mandate a model that has significant design flaws, and as proposed, places too much risk on providers with too little opportunity for reward in the form of shared savings, especially considering the significant upfront investments required."

Along with spinal fusions, the mandatory payment model would bundle payments for lower extremity joint replacements and surgical hip femur fracture treatment. Other cases included are coronary artery bypass grafts and major bowel procedures. Those surgical episodes comprise more than 11% of inpatient prospective payment system payments; outpatient payments aren't included.

The AHA in its statement is urging CMS to make the model voluntary.

Spine surgeon Brian Gantwerker, MD, said although the proposal might look good on the surface it doesn't address deeper complexities.

"It has some fatal flaws," Dr. Gantwerker, of The Craniospinal Center of Los Angeles, said. "First, no two spine surgeries are alike. There are often considerations and technical issues that can cause surgeries to last longer or patients to stay longer. Second, it is not adjusted for locale. Some surgeries cost more because they are in more expensive geographical areas. Third, it supposes that surgeons will get a fair share of the money once it ends up in the coffers of the hospital. I mean, seriously? 

"When have the foxes guarding the henhouse worked out well for the chickens? 

"CMS needs a refresh and needs to stop recirculating insurance people through its ranks, trying to save the insurers, and not the public, money."

The International Society for the Advancement of Spine Surgery submitted its comments for the proposed rule, which would launch in January 2026. ISASS commended the effort to streamline healthcare costs but also raised concerns about the model's implications for spinal fusions, Morgan Lorio, MD, ISASS' chair of coding and reimbursement task force and incoming president, said.

"The inclusion of cervical fusion codes (22551 and 22554) appears redundant, given recent prior authorization controls," Dr. Lorio said. "Removal of these codes would establish consistency in surgical expectations. We appreciate CMS' exclusion of new technology add-on and transitional pass-through payments from the model, recognizing the importance of incentivizing innovation. Concerns persist regarding post-spinal fusion referrals to primary care, given the shortage of primary care physicians and reluctance to accept Medicare patients. The absence of MS-DRG 402 from the model raises questions, considering its relevance to spinal fusions. Lastly, we caution against incentivizing short-term metrics over long-term patient outcomes, advocating for comprehensive assessments before spinal fusion's inclusion in the TEAM model."

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