The Association Between Hospital Finances and Complications After Complex Abdominal Surgery: Deficiencies in the Current Health Care Reimbursement System and Implications for the Future (original) (raw)
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Relationship Between Occurrence of Surgical Complications and Hospital Finances
JAMA, 2013
ATIONAL HEALTH EXPENDItures for surgical procedures are estimated to cost 400billionannuallyandareexpectedtooutpaceeconomicgrowthduringthenext10years.1,2Therateofinpatientsurgicalcomplicationsissignificant,withestimatesrangingfrom3400 billion annually and are expected to outpace economic growth during the next 10 years. 1,2 The rate of inpatient surgical complications is significant, with estimates ranging from 3% to 17.4%, depending on type of procedure, type of complications, length of follow-up, and data analyzed. 3-8 In addition to patient harm, major complications add substantial costs, previously estimated at 400billionannuallyandareexpectedtooutpaceeconomicgrowthduringthenext10years.1,2Therateofinpatientsurgicalcomplicationsissignificant,withestimatesrangingfrom311 500 per patient. 9 Effective methods for reducing surgical complications have been identified. 8-10 However, hospitals have been slow to implement them. 11 Resource constraints may be a factor. Quality improvement efforts often require expenditures for staff time and technologies, and financial benefits are uncertain. 12,13 Improvements can reduce revenues under per diem reimbursement schemes and even diagnosis related group-based reimbursement because complications can result in severityadjustmentsordiagnosisrelatedgroup changes that increase revenues. For example , a colectomy patient's diagnosis couldchangefromcode148(majorbowel procedure with complications) to 483 (tracheostomy with mechanical ventilation Ͼ96 hours), triggering a 5-fold increase in Medicare reimbursement. 14 Ontheotherhand,somecomplicationssuch as certain "never event" complications-are no longer reimbursed by many payers. 15,16 Previous estimates suggest that reducing surgical complications could harm hospital financial results but For editorial comment see p 1634.
Impact of Surgical Quality Improvement on Payments in Medicare Patients
Annals of Surgery, 2015
Objective-To examine the financial impact of quality improvement using Medicare payment data. Background-Demonstrating a business case for quality improvement-i.e. that fewer complications translates into lower costs-is essential to justify investment in quality improvement. Prior research is limited to cross-sectional studies showing that patients with complications have higher costs. We designed a study to better evaluate the relationship between payments and complications by using quality improvement itself as a measured outcome. Methods-We used national Medicare data for patients undergoing general (n= 1,485,667) and vascular (n= 531,951) procedures. We calculated hospitals' rates of serious complications in two time periods: 2003-2004 and 2009-2010. We sorted hospitals into quintiles by the change in complication rates across these time periods. Costs were assessed using price-standardized Medicare payments, and regression analyses used to determine the average change in payments over time. Results-There was significant change in serious complication rates across the two time periods. The top 20% of hospitals demonstrated a 38% decrease (14.3% vs. 11.6%, p<.001) in complications; in contrast the bottom 20% demonstrated a 25% increase (11.1% vs. 16.5%, p<. 001). There was a strong relationship between quality improvement and payments. The top hospitals reduced their payments
Perioperative medicine (London, England), 2014
When hospitals suffer financial losses when postoperative complications occur, they may have a direct financial incentive to initiate quality improvement programs. The purpose of this research was to determine the relationship between complications following open colectomy and hospital finances. After obtaining Institutional Review Board approval, we conducted a retrospective chart review of 276 open colectomies performed at the Hospital of the University of Pennsylvania. The medical records were manually reviewed for complications that occurred within 30 days after surgery. Financial information, including total, fixed and variable costs, was obtained from the hospital's cost accounting database. Reimbursement assuming payment by Medicare was calculated. Differences in costs, reimbursements and total margins were analyzed. Of 276 patient records reviewed, 61 (22%) of the patients experienced postoperative complications. When complications occurred, mean total costs increased fr...
Surgery, 2015
Readmission rates after operative procedures are used increasingly as a measure of hospital care quality. Patient access to care may influence readmission rates. The objective of this study was to determine the relationship between patient cost-sharing, insurance arrangements, and the risk of postoperative readmissions. Using the MarketScan Research Database (n = 121,002), we examined privately insured, nonelderly patients who underwent abdominal surgery in 2010. The main outcome measures were risk-adjusted unplanned readmissions within 7 days and 30 days of discharge. Odds of readmissions were compared with multivariable logistic regression models. In adjusted models, $1,284 increase in patient out-of-pocket payments during index admission (a difference of one standard deviation) was associated with 19% decrease in the odds of 7-day readmission (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.78-0.85) and 17% decrease in the odds of 30-day readmission (OR 0.83, 95% CI 0.81-0.8...
JAMA Network Open
IMPORTANCE Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers. OBJECTIVE To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-indifferences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between
Operative Outcome And Hospital Cost
Journal of Thoracic and Cardiovascular Surgery, 1998
Because of concern about increasing health care costs, we undertook a study to find patient risk factors associated with increased hospital costs and to evaluate the relationship between increased cost and in-hospital mortality and serious morbidity. Methods: More than 100 patient variables were screened in 1221 patients undergoing cardiac procedures. Simultaneously, patient hospital costs were computed from the cost-to-charge ratio. Univariate and multivariate statistics were used to explore the relationship between hospital cost and patient outcomes, including operative death, in-hospital morbidity, and length of stay. Results: The greatest costs were for 31 patients who did not survive operation ($74,466, 95% confidence interval 27,102to27,102 to 27,102to198,025), greater than the costs for 120 patients who had serious, nonfatal morbidity ($60,335, 95% confidence interval 28,381to28,381 to 28,381to130,897, p ؍ 0.02) and those for 1070 patients who survived operation without complication ($31,459, 95% confidence interval 21,944to21,944 to 21,944to49,849, p ؍ 0.001). Breakdown of the components of hospital costs in fatalities and in cases with nonfatal complications revealed that the greatest contributions were in anesthesia and operating room costs. Significant (by stepwise linear regression analysis) independent risks for increased hospital cost were as follows (in order of decreasing importance): (1) preoperative congestive heart failure, (2) serum creatinine level greater than 2.5 mg/dl, (3) New York state predicted mortality risk, (4), type of operation (coronary artery bypass grafting, valve, valve plus coronary artery bypass grafting, or other), (5) preoperative hematocrit, (6) need for reoperative procedure, (7) operative priority, and (8) sex. These risks were different than those for in-hospitality death or increased length of stay. Hospital cost correlated with length of stay (r ؍ 0.63, p < 0.001), but there were many outliers at the high end of the hospital cost spectrum. Conclusions: We conclude that operative death is the most costly outcome; length of stay is an unreliable indicator of hospital cost, especially at the high end of the cost spectrum; risks of increased hospital cost are different than those for perioperative mortality or increased length of stay; and ventricular dysfunction in elderly patients undergoing urgent operations for other than coronary disease is associated with increased cost. Certain patient factors, such as preoperative anemia and congestive heart failure, are amenable to preoperative intervention to reduce costs, and a high-risk patient profile can serve as a target for cost-reduction strategies. (J Thorac Cardiovasc Surg 1998;115:593-603) Ferraris, Ferraris, Singh 5 9 5 CHF, Congestive heart failure; OR, operating room.
Diseases of the Colon & Rectum, 2020
BACKGROUND: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals. OBJECTIVE: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections. DESIGN: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs. SETTING: This study was conducted at an academic medical center. PATIENTS: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/ comorbidities) were selected. MAIN OUTCOME MEASURES: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses. RESULTS: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111
Trends in the quality and cost of inpatient surgical procedures in the United States, 2002–2015
PLOS ONE, 2021
Objectives This study documents trends in risk-adjusted quality and cost for a variety of inpatient surgical procedures among Medicare beneficiaries from 2002 through 2015, which can provide valuable insight on future strategies to improve public health and health care. Methods We focused on 11 classes of inpatient surgery, defined by the Agency for Health Research and Quality’s (AHRQ’s) Clinical Classification System. The surgical classes studied included a wide range of surgeries, including tracheostomy, heart valve procedures, colorectal resection, and wound debridement, among others. For each surgical class, we assessed trends in treatment costs and quality outcomes, as defined by 30-day survival without unplanned readmissions, among Medicare beneficiaries receiving these procedures during hospital stays. Quality and costs were adjusted for patient severity based on demographics, comorbidities, and community context. We also explored surgical innovations of these 11 classes of i...