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Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform.

ABSTRACT: BACKGROUND:In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65?years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy. METHODS:Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure. RESULTS:After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (?$1606, for CABG). CONCLUSIONS:This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

SUBMITTER: Wynn-Jones W

PROVIDER: S-EPMC6873455 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform.

Wynn-Jones W W Koehlmoos T P TP Tompkins C C Navathe A A Lipsitz S S Kwon N K NK Learn P A PA Madsen C C Schoenfeld A A Weissman J S JS

BMC health services research 20191121 1

<h4>Background</h4>In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost ...[more]

PMID: 31752866

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Project description:BackgroundMisuse of prescription opioids is a well-established contributor to the US opioid epidemic. The primary objective of this study was to identify which level of care delivery (ie patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures.Study designElectronic health record data from a large multihospital healthcare system were used in conjunction with random-effect models to examine variation in opioid prescribing practices after similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation.ResultsAmong 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5 mg oxycodone tablets after surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic Black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider.ConclusionsGiven the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.

Project description:Importance:Increasing use of robotic surgery for common surgical procedures with limited evidence and unclear clinical benefit is raising concern. Analyses of population-based trends in practice and how hospitals' acquisition of robotic surgical technologies is associated with their use are limited. Objective:To characterize trends in the use of robotic surgery for common surgical procedures. Design, Setting, and Participants:This cohort study used clinical registry data from Michigan from January 1, 2012, through June 30, 2018. Trends were characterized in the use of robotic surgery for common procedures for which traditional laparoscopic minimally invasive surgery was already considered a safe and effective approach for most surgeons when clinically feasible. A multigroup interrupted time series analysis was performed to determine how procedural approaches (open, laparoscopic, and robotic) change after hospitals launch a robotic surgery program. Data were analyzed from March 1 through April 19, 2019. Exposures:Initiation of robotic surgery. Main Outcomes and Measures:Procedure approach (ie, robotic, open, or laparoscopic). Results:The study cohort included 169?404 patients (mean [SD] age, 55.4 [16.9] years; 90?595 women [53.5%]) at 73 hospitals. The use of robotic surgery increased from 1.8% in 2012 to 15.1% in 2018 (8.4-fold increase; slope, 2.1% per year; 95% CI, 1.9%-2.3%). For certain procedures, the magnitude of the increase was greater; for example, for inguinal hernia repair, the use of robotic surgery increased from 0.7% to 28.8% (41.1-fold change; slope, 5.4% per year; 95% CI, 5.1%-5.7%). The use of robotic surgery increased 8.8% in the first 4 years after hospitals began performing robotic surgery (2.8% per year; 95% CI, 2.7%-2.9%). This trend was associated with a decrease in laparoscopic surgery from 53.2% to 51.3% (difference, -1.9%; 95% CI, -2.2% to -1.6%). Before adopting robotic surgery, hospitals' use of laparoscopic surgery increased 1.3% per year. After adopting robotic surgery, the use of laparoscopic surgery declined 0.3% (difference in trends, -1.6%; 95% CI, -1.7% to -1.5%). Conclusions and Relevance:These results suggest that robotic surgery has continued to diffuse across a broad range of common surgical procedures. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery.

Project description:ImportanceThe overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.ObjectivesTo describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills.Design, setting, and participantsThe Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing.ExposuresLength of initial prescription for opioid pain medication.Main outcomes and measuresNeed for an additional subsequent prescription for opioid pain medication, or a refill.ResultsOf the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women's health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%).Conclusions and relevanceIdeally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women's health procedures, and 6 to 15 days for musculoskeletal procedures.

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Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform.

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Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform.

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