Introduction: Improved understanding of the pre and postoperative trends in costs and healthcare resource utilization (HCRU) is needed to better inform patient expectations and aid in the development of strategies to minimize the significant healthcare burden associated with lumbar spine surgery. The purpose of this study was to examine the time course of costs and HCRU surrounding lumbar spine surgery in a national claims cohort.

Methods:  Longitudinal analyses of adult patients undergoing elective primary single-level lumbar surgery for stenosis from the IBM® Marketscan® Research Databases 2007—2015 were performed.  Patients were required to have continuous health plan enrollment 2 years pre- and postoperatively. Outcomes included monthly rates of HCRU (15 categories) and monthly gross covered payments (2015 US dollars) overall, by HCRU category, and by whether they were spine versus non-spine-related. All available patients were utilized for analysis of HCRU. For analysis of payments, patients on non-capitated health plans providing accurate financial information were analyzed. Trends in payments and HCRU were plotted on a monthly basis pre- and post-surgery and assessed with regression models. Relationships with demographics, surgical factors, and comorbidities were assessed with repeated measures generalized estimating equations.

Results:  The final cohort included 22,182 patients (age 58±13 years, 48.9% female). 27.1% of cases involved a fusion. Payments rose steeply 6 months prior to surgery, reaching a peak of $1,402 ($634, $2,827) 1 month prior to surgery (Figure 1). This was driven by an increase in radiology, office visits, PT, injections, prescription medications, ER encounters, and inpatient admissions (Figure 2). In the first month postoperatively, payments achieved levels lower than 5 months preoperatively.  The median monthly payments continued to decline gradually over the 2 years postoperatively primarily due to a decrease in non-spine-related payments. Most HCRU categories remained elevated 2 years postoperatively relative to 2 years preoperatively; however, patients aged 4 years over the course of follow up.  Patients with a fusion component to their surgeries had higher payments and HCRU preoperatively, and this did not resolve postoperatively. Variations in payments and HCRU were evident among plan types, with patients on employer-sponsored supplemental Medicare coverage utilizing more inpatient, ER, and inpatient rehabilitation & skilled nursing facilities.  Patients on high-deductible plans had fewer payments and HCRU across all categories; however, we are unable to distinguish whether this was due to using fewer services or due to payment out of pocket. By 2 years postoperatively, 54% of patients had lower median monthly healthcare payments relative to 2 years preoperatively, and when looking at spine-related care, specifically, 68% had lower payments

Discussion: This is the first study to characterize time trends in direct healthcare payments and HCRU over an extended period preceding and following spine surgery. Despite patients aging 4 years over the course of longitudinal follow up, half lower overall median monthly healthcare payments and nearly 7 in 10 had lower spine-related healthcare payments 2 years postoperatively relative to 2 years preoperatively. Differences among plan types potentially highlight disparities in access to care and plan-related financial mediators of patients’ healthcare resource utilization.