Authors: Zachary Adam Medress, MD; Beatrice Ugiliweneza; Jonathon Parker, MD, PhD; Dengzhi Wang, MS; Eric Burton, MD; Shiao Woo, MD; Maxwell Boakye; Stephen Skirboll, MD (Stanford, CA)

Introduction:

Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Care Improvement Initiative (BPCI) in order to improve care coordination and cost efficiency. BPCI has been implemented for orthopedic, cardiac, and spine procedures, but has not yet been applied to cranial neurosurgical procedures. We project the cost of episode-based bundled payments for cranial neurosurgical procedures.

Methods:

We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment costs for common cranial neurosurgical procedures. Operations were classified into four groups: Craniotomy for unruptured aneurysm, craniotomy for meningioma, craniotomy for malignant glioma, and craniotomy for metastasis. We project 30-, 60-, and 90-day bundle payments for each category, and analyze the contributions of post-discharge costs to total bundle payments at each time point.

Results:

We identified 15,276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-day bundle projected costs ranging from $58,200 for craniotomy for meningioma to $102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected costs for a 30-day bundle and 70.5% of projected costs for a 90-day bundle. Multivariate analysis showed that medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle costs.

Conclusion:

For the first time in our knowledge, we report projected costs of 30-, 60-, and 90-day episode-based bundled payments for common elective vascular and tumor cranial operations. As previously identified in the orthopedic literature, there is significant cost variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, post-discharge costs significantly impact total bundle payments in cranial neurosurgery. We believe projected bundle costs will inform future health policy in cranial neurosurgery.