To Cut is to Cure: The Surgeon's Role in Improving Value (original) (raw)
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JAMA, 2015
Program (ACS NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if participation in the program improves outcomes and reduces costs relative to nonparticipating hospitals. OBJECTIVE To evaluate the association of enrollment and participation in the ACS NSQIP with outcomes and Medicare payments compared with control hospitals that did not participate in the program. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study using national Medicare data (2003-2012) for a total of 1 226 479 patients undergoing general and vascular surgery at 263 hospitals participating in ACS NSQIP and 526 nonparticipating hospitals. A difference-indifferences analytic approach was used to evaluate whether participation in ACS NSQIP was associated with improved outcomes and reduced Medicare payments compared with nonparticipating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS NSQIP hospital). MAIN OUTCOMES AND MEASURES Thirty-day mortality, serious complications (eg, pneumonia, myocardial infarction, or acute renal failure and a length of stay >75th percentile), reoperation, and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days after discharge. RESULTS After accounting for patient factors and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes at 1, 2, or 3 years after (vs before) enrollment in ACS NSQIP. For example, in analyses comparing outcomes at 3 years after (vs before) enrollment, there were no statistically significant differences in risk-adjusted 30-day mortality (4.3% after enrollment vs 4.5% before enrollment; relative risk [RR], 0.96 [95% CI, 0.89 to 1.03]), serious complications (11.1% after enrollment vs 11.0% before enrollment; RR, 0.96 [95% CI, 0.91 to 1.00]), reoperations (0.49% after enrollment vs 0.45% before enrollment; RR, 0.97 [95% CI, 0.77 to 1.16]), or readmissions (13.3% after enrollment vs 12.8% before enrollment; RR, 0.99 [95% CI, 0.96 to 1.03]). There were also no differences at 3 years after (vs before) enrollment in mean total Medicare payments ($40
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
Development of Episode-Based Cost Measures for the US Medicare Merit-based Incentive Payment System
JAMA Health Forum
IMPORTANCE The Merit-based Incentive Payment System (MIPS), established as part of the Quality Payment Program, is a Medicare value-based payment program that evaluates clinicians' performance across 4 categories: quality, cost, promoting interoperability, and improvement activities. The cost category includes novel episode-based measures designed for targeted evaluation of the resource use of specific conditions. This report describes the development of episode-based cost measures and their role in the shift from volume-based to value-based purchasing. OBJECTIVES Episode-based cost measures focus on resource use related to the treatment of a specific condition or procedure. The measures exclude health care costs unrelated to the condition or procedure of focus. The episode-based cost measures provide a nuanced examination of resource use that can be used alongside quality metrics to identify opportunities to improve the value by capturing costs that are clinically related to the care being delivered within a given patient-clinician relationship of care delivered to patients. These measures were developed with the input of clinical committees composed of over 320 clinicians from 127 specialty societies and stakeholder organizations. The MIPS program currently evaluates clinician cost category performance based on 2 population-based cost measures (Medicare spending per beneficiary and total per capita costs) in addition to 18 episode-based cost measures. Additional episode-based cost measures are currently under development. CONCLUSIONS AND RELEVANCE The transition to value-based payment requires an accurate assessment of clinician effect on health care quality and cost. The use of episode-based cost measures to assess clinician influence on health care costs for high-priority conditions and procedures is an important step. The Centers for Medicare & Medicaid Services is introducing MIPS Value Pathways that will align episode-based cost measures with related quality measures to further incentivize the transition from fee-for-service to value-based care.
Development of alternative payment models for surgical care
Seminars in Colon and Rectal Surgery, 2018
Alternative Payment Models (APMs) have been of growing importance in the Medicare Program for several years. Recently passed laws have created additional incentives for the creation of, and participation in APMs that meet certain requirements related to quality, risk, and use of certified EHR technology. The American College of Surgeons has undertaken an effort to develop an APM that recognize the importance of team-based, patient centered care and surgeon leadership in improving outcomes and patient experience while allowing surgeons to share in savings from reductions in cost.
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
Who Pays for Poor Surgical Quality? Building a Business Case for Quality Improvement
Journal of the American College of Surgeons, 2006
BACKGROUND: Both providers and payors bear the financial risk associated with complications of poor quality care. But the stakeholder who bears the largest burden of this risk has a strong incentive to support quality improvement activities. The goal of the present study was to determine whether hospitals or payors incur a larger burden of increased hospital costs associated with complications. STUDY DESIGN: We merged clinical data for 1,008 surgical patients from the private sector National Surgical Quality Improvement Program to the internal cost-accounting database of a large university hospital. We then determined the marginal costs of surgical complications from the perspective of both hospitals (changes in profit and profit margin) and payors (increase in reimbursement paid to the hospital). In our analyses of cost and reimbursement, we adjusted for procedure complexity and patient characteristics using multivariate linear regression.
Does relative value unit–based compensation shortchange the acute care surgeon?
Journal of Trauma and Acute Care Surgery, 2014
BACKGROUND: Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures.
American Journal of Medical Quality, 2009
Medicare has introduced a number of new payment initiatives that will have a profound effect on hospital reimbursement and quality and safety ratings. The new medical severity diagnosis-related group (MS-DRG) payment system adds a number of new DRG categories to more adequately account for patient severity. The new present-on-admission (POA) initiative is designed to withhold additional reimbursement for selected complications that were not recorded as being POA but that occurred during the course of the hospitalization. The recovery audit contract requires hospitals to repay Medicare for services deemed not clinically necessary based on retrospective chart review. Reimbursement and quality rankings for each of these initiatives are based on the extent and thoroughness of physician chart documentation. Physicians must understand the importance of their role and responsibilities in this process and embrace what needs to be done through appropriate education, coaching, and guidance, which leads to more effective chart documentation. (Am J Med Qual XXXX;XX:xx-xx)