Evaluating the Relationship Between Hospital Price Markup and Outcomes After Anterior Cervical Discectomy and Fusion

Study Design. Retrospective cohort study. Objective. To evaluate the association between hospital price markup and perioperative and long-term outcomes following elective anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Hospital price markup, defined as the ratio of billed charges to actual costs, varies widely across U.S. institutions and is largely unregulated. While prior studies in general surgery have linked high-markup hospitals to poorer outcomes, this relationship has not been characterized in cervical spine surgery. Methods. Adult patients undergoing elective ACDF from 2016 to 2022 were identified from the PINC AI Healthcare Database. Hospital-level charge-to-cost ratios were calculated using ACDF encounters, and hospitals in the highest regional markup decile were designated as high-markup hospitals (HMH). Outcomes included perioperative complications, 30-day readmission, long-term complications, and reoperation. Multivariable regression models adjusted for patient-, procedural-, and hospital-level covariates. Results. A total of 241,965 patients were included; 22,495 (9.3%) were treated at HMH. Mean markup was significantly higher at HMH versus non-HMH (7.81x vs. 4.10x, P <0.001). After multivariable adjustment, HMH were associated with higher 30-day readmission (2.94% vs. 2.63%, P =0.007), perioperative complications (2.61% vs. 2.36%, P =0.020), long-term complications (6.99% vs. 6.58%, P =0.021), and reoperation (4.07% vs. 3.75%, P =0.020). Conclusion. Among patients undergoing elective ACDF, treatment at high-markup hospitals was independently associated with worse postoperative outcomes despite greater expenditure. These findings challenge the assumption that higher-cost care confers higher quality and have important implications for spine surgery healthcare policy. Level of Evidence. III