Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review.

OBJECTIVES: To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions. BACKGROUND SUMMARY: Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear. METHODS: A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion. RESULTS: Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited. CONCLUSIONS: Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.

Variation in pre-operative insurance requirements for bariatric surgery.

BACKGROUND: For patients who wish to undergo bariatric surgery, variation in pre-operative insurance requirements may represent inequity across insurance plan types. We conducted a cross-sectional assessment of the variation in pre-operative insurance requirements. METHODS: Original insurance policy documents for pre-operative requirements were obtained from bariatric surgery programs across the entire USA and online insurance portals. Insurance programs analyzed include commercial, Medicaid, and Medicare/TriCare plans. Poisson regression adjusting for U.S. Census region was used to evaluate variation in pre-operative requirements. Analyses were done at the insurance plan level. Our primary outcome was number of requirements required by each plan by insurance type. Our secondary outcome was number of months required to participate in medically supervised weight loss (MSWL). RESULTS: Among 43 insurance plans reviewed, representing commercial (60.5%), Medicaid (25.6%), and Medicare/TriCare (14.0%) plans, the number of pre-operative requirements ranged from 1 to 8. Adjusted Poisson regression showed significant variation in pre-operative requirements across plan types with Medicaid-insured patients required to fulfill the greatest number (4.1, 95%CI 2.7 to 5.4) compared to 2.7 (95%CI 2.2 to 3.2, P = 0.028) for commercially insured patients and 2.1 (95%CI 1.1 to 3.1, P = 0.047) for Medicare/TriCare-insured patients. Medicaid-insured patients were also required to complete a greater number of months in MSWL (6.6, 95%CI 5.5 to 7.6) compared to commercially (3.8, 95%CI 2.9 to 4.8, P < .001) and Medicare/TriCare-insured patients (1.7, 95%CI 0.3 to 3.0, P = .001). CONCLUSION: The greater frequency of pre-operative requirements in Medicaid plans compared to Medicare/TriCare and commercial plans demonstrates inequity across insurance types which may negatively impact access to bariatric surgery. Pre-operative insurance requirements must be reevaluated and standardized using established evidence to ensure all individuals have access to this life-saving intervention.