Mok James M, Martinez Maximilian, Smith Harvey E, Sciubba Daniel M, Passias Peter G, Schoenfeld Andrew, Isaacs Robert E, Vaccaro Alexander R, Radcliff Kris E
Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.
Rutgers University - New Jersey Medical School, Newark, NJ.
Int J Spine Surg. 2016 May 16;10:19. doi: 10.14444/3019. eCollection 2016.
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.
在捆绑支付系统中，单次支付涵盖与单次治疗过程相关的所有费用。由于治疗过程明确，脊柱手术可能非常适合捆绑支付，但尚未研究其对当前医疗实践的影响。我们试图研究一种对资源利用具有经济抑制作用的理论捆绑支付策略将如何影响医疗实践模式。
对脊柱外科医生进行了一项多项选择调查，描述了八种临床情景。询问受访者他们目前的医疗实践，然后是他们在假设的捆绑支付系统中的医疗实践。受访者可以从多种类型的植入物、骨移植材料以及外科医生可自行决定使用的其他资源中进行选择。
43名受访者完成了调查。在每种情景中，24% - 49%的受访者至少改变了管理的一个方面。在四种情景中，未使用植入物进行手术的比例没有变化，在四种情景中平均增加了8%。在所有情景中，自体髂嵴骨移植的使用平均增加了18%。在所有情景中，神经监测的使用平均减少了21%。成本差异无统计学意义。
对资源利用的经济抑制可能会导致外科医生的医疗实践发生一些变化，但这些变化似乎仅限于对患者益处不太明确的项目。占术中成本大部分的植入物选择没有显著变化。仅针对与手术实践相关的围手术期成本的捆绑策略可能不会产生实质性节省，同时还会限制对患者护理可能有益的治疗方法的使用。
5级。
