Economics of the Treatment of Craniospinal Chordoma and Chondrosarcoma and the Feasibility of using the Bundled Payment Model

Healthcare expenditures are continuously rising in the United States. The current fee-for-service (FFS) system reimburses health care providers based on the volume of services performed. Due to the risk of performing unnecessary tests, the Centers for Medicare and Medicaid Services (CMS) created a new reimbursement model called the “Bundled Payment for Care Improvement (BPCI).” This model reimburses providers a prespecified bundled payment in advance to cover all possible services rendered to patients within a specified time window around the treatment, including eventual complications. Chordoma/chondrosarcoma are slow-growing and locally aggressive malignant primary bony tumors. Treatment includes maximum safe surgical resection and radiotherapy with substantial risk for recurrence which necessitates observation and further treatment. These factors make these conditions valuable to explore the feasibility of the BPCI model. Data were obtained from the United States MarketScan database, patients were identified using the International Classification of Diseases 10 codes. A total of 1,755 patients were included, 1,412 had cranial (group 1) and 343 had a mobile spine (group 2) chordoma/chondrosarcoma. For Index hospitalization, the median length of stay (days) was 4 and 6, median total payments were 35401$ and 42303$, complication rates were 30% and 33.5%, for group 1 and 2. Three months postdischarge period, hospital readmission rates were 21% and 39%, and payments were 29824$ and 28969 $, for group 1 and 2. Combined median payments for the index hospitalization and 90 days postdischarge were 79752$ and 102366$ for group 1 and 2. For the second 3 months payments were 87% and 93% of the first 3 months for groups 1 and 2. For the first 6 months after discharge, readmission rates were 30% and 45% for group 1 and 2. For the second 6 months after discharge, readmission rates dropped to 14% and 7% for groups 1 and 2. This was associated with a decline in payments. Payments during the second 6 months after discharge were 52% and 62% of payments during the 1st 6 months for group 1and 2. These findings indicate that the excessive cost needed to manage craniospinal chordoma and chondrosarcoma extend over an extended period. The BPCI may not be feasible for conditions with a high rate of complications and readmission, and an increased need for outpatient services. It poses a risk of monetary loss to the hospital. The success of BPCI requires a joint effort between insurers and hospitals. It should consider patients’ comorbidities, the complexity of the disease, inherent risk for complications. Also, it is well-documented centers with high case volume is associated with lower complications, better outcomes, and lower cost. Therefore, it may be of importance for certain complex neurosurgical conditions to be managed at centers of excellence. From the hospital side, the adoption of programs like Enhanced Recovery After Surgery or Enhanced Perioperative Care which aimed at decreasing length of stay, complications, and readmissions may be valuable to improve outcomes and decrease cost.