Health access, health disparities, and Medicare's transforming episode accountability model (TEAM) in the field of spine surgery.

In the past, many health reform efforts have been touted as a means to tangentially reduce healthcare disparities. Few have shown any demonstrable efficacy in this arena. There is reasonable concern that the machinations of Medicare's Transforming Episode Accountability Model (TEAM) may also exert unintended effects on health access and delivery, potentially worsening existent disparities for racial and ethnic minorities as well as other vulnerable populations. As TEAM has yet to be implemented, this review intends to prognosticate potential pitfalls and behaviors that may be motivated by this project that could otherwise lead to worsening healthcare disparities within spine fusion care. We present a narrative review with our prognostications regarding mechanisms and behaviors that may be influenced by TEAM and that could result in worsening healthcare disparities and/or reduced access to care for vulnerable populations. These are informed by published experiences with other health reform efforts including centers of excellence, bundled payment programs, Accountable Care Organizations and Comprehensive Care for Joint Replacement. Based on previous published experiences with similar health reform initiatives, we believe there are several areas in which TEAM may potentiate or worsen existing healthcare disparities. These include the areas of access to care, undertreatment and healthcare segregation, as well as adverse behaviors such as cherry picking, lemon dropping and asymmetric pressure on small hospitals and safety-net institutions. There remain several aspects of TEAM that could limit access to care and aggravate healthcare disparities. Some of these behaviors could result in implicit or explicit undertreatment, restricted access to care and worsened healthcare segregation with negative feedback loops that continue to syphon resources from smaller hospitals and safety-net hospitals resulting in deterioration in the quality of care and general health of the already vulnerable populations these facilities serve.