290. The impact of insurance payor on hospital length of stay and discharge time in adult patients undergoing elective spine surgery

BACKGROUND CONTEXT ERAS pathways are evidence-based protocols designed to reduce the surgical stress response and facilitate return to function, which typically results in a significant decrease in length of stay. After implementation of such a program at our institution, length of stay only transiently decreased. PURPOSE This study looks to identify barriers to timely discharge, and to assess a causal relationship with clearance from insurance payors. STUDY DESIGN/SETTING This is a retrospective cohort study of 105 consecutive patients undergoing elective spinal surgery on an ERAS pathway at a tertiary academic center. PATIENT SAMPLE N/A OUTCOME MEASURES N/A METHODS Prior to admission, all patients were assigned to intermediate (n=31) or complex (n=74) ERAS pathways according to their scheduled operation. Demographic data and variables related to comorbidities, insurance payor, length of stay, intra-and postoperative complications, discharge destination, and the date of medical clearance to discharge home or to a rehabilitation facility were recorded. The days stayed beyond medical clearance was calculated as the difference between the date of medical clearance and the actual date of discharge. Each operation was categorized according to the involvement of spinal fusion and by the number of vertebral levels. After patients were classified by payor type, Private Insurance, Medicare, and Triwest, the contracted payor for the Veterans Administration, were compared. RESULTS In complex pathway patients, there was no significant difference between the demographics, complication rates, or operative parameters in any of the groups. When compared overall and individually, there was a significant difference in mean length of stay between all groups (Private vs Medicare vs Triwest, 6.5 vs 5.1 vs 15.5 days, p = 0.002) that was mirrored in the days stayed beyond medical clearance (1.4 vs 0.3 vs 10, p = 0.001). This delay can translate into additional costs ranging between $14,000 and $140,000 per patient. In the intermediate pathway, Medicare patients were significantly older than Private Insurance or Triwest patients (72.7 vs 54.1 vs 54.6 years, p = 0.001), and the incidence of comorbid cancer was greater in the Private Insurance and Triwest cohorts compared to Medicare (50% vs 38% vs 0%, p = 0.007), but the remaining demographics were not different. There was no difference in length of stay (4 vs 3.15 vs 4.1 days, Private vs Medicare vs Triwest, p = 0.747), but the days beyond medical clearance was significant (0.7 vs 0 vs 1.5, p = 0.031), and it mirrored the complex group. The levels involved and fusion in each cohort were not different. 49% of patients on the complex pathway were discharged to inpatient rehabilitation facilities compared to 16% on the intermediate pathway. CONCLUSIONS Insurance payors can influence length of stay by delaying discharge authorization after spine surgery. The days stayed beyond medical clearance followed a regular pattern regardless of the pathway, with Medicare having less of a delay than Private Insurance, which had less of a delay than Triwest. When involving discharge to inpatient rehabilitation, this delay can significantly affect the total length of stay. Hospital stay beyond what is medically required represents a delay in appropriate patient care and unnecessary expenses that can be draining on our healthcare system, and that represents an opportunity for improvement across multiple procedures and specialties. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.