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Levy BE, Mangino AA, Castle JT, Stephens WA, McDonald HG, Patel JA, Beck SJ, Bhakta AS. Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization. Am J Surg 2024; 232:102-106. [PMID: 38281872 DOI: 10.1016/j.amjsurg.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD). METHODS The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption. RESULTS Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion. CONCLUSION In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.
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Affiliation(s)
- Brittany E Levy
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Anthony A Mangino
- University of Kentucky Department of Biostatistics, 111 Washington Ave, Lexington, KY, 40536, USA.
| | - Jennifer T Castle
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Wesley A Stephens
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Hannah G McDonald
- University of Kentucky Department of Surgery, 780 Rose Street, Lexington, KY, 40536, USA.
| | - Jitesh A Patel
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
| | - Sandra J Beck
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
| | - Avinash S Bhakta
- University of Kentucky Division of Colorectal Surgery, 780 Rose Street, Lexington, KY 40536, USA.
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2
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Herrel LA, Yan P, Modi P, Adler-Milstein J, Ryan AM, Hollingsworth JM. Association of Medicare Beneficiary and Hospital Accountable Care Organization Alignment With Surgical Cost Savings. JAMA HEALTH FORUM 2022; 3:e224817. [PMID: 36547947 PMCID: PMC9857079 DOI: 10.1001/jamahealthforum.2022.4817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Importance Although Medicare accountable care organizations (ACOs) account for half of program expenditures, whether ACOs are associated with surgical spending warrants further study. Objective To assess whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs. Design, Setting, and Participants This retrospective cohort study was conducted between 2020 and 2022 using US Medicare data from a 20% random sample of beneficiaries. Individuals 18 years of age and older and without kidney failure who had a surgical admission between 2008 and 2015 were included. For each study year, distinction was made between beneficiaries assigned to an ACO and those who were not, as well as between admissions to ACO-participating and nonparticipating hospitals. Exposures Time-varying binary indicators for beneficiary ACO assignment and hospital ACO participation and an interaction between them. Main Outcomes and Measures Ninety-day, price-standardized total episode payments. Multivariable 2-way fixed-effects models were estimated. Results During the study period, 2 797 337 surgical admissions (6% of which involved ACO-assigned beneficiaries) occurred at 3427 hospitals (17% ACO participating). Total Medicare payments for 90-day surgical episodes were lowest when ACO-assigned beneficiaries underwent surgery at a hospital participating in the same ACO as the beneficiary ($26 635 [95% CI, $26 426-$26 844]). The highest payments were for unassigned beneficiaries treated at participating hospitals ($27 373 [95% CI, $27 232-$27 514]) or nonparticipating hospitals ($27 303 [95% CI, $27 291-$27 314]). Assigned beneficiaries treated at hospitals participating in a different ACO and assigned beneficiaries treated at nonparticipating hospitals had similar payments (for participating hospitals, $27 003 [95% CI, $26 739-$27 267] and for nonparticipating hospitals, $26 928 [95% CI, $26 796-$27 059]). A notable factor in the observed differences in surgical episode costs was lower spending on postacute care services. Conclusions and Relevance In this cohort study evaluating hospital and beneficiary ACO alignment and surgical spending, savings were noted for beneficiaries treated at hospitals in the same ACO. Allowing ACOs to encourage or require surgical procedures in their own hospitals could lower Medicare spending on surgery.
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Affiliation(s)
- Lindsey A. Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Phyllis Yan
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Parth Modi
- Department of Urology, University of Chicago, Chicago, Illinois
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco
| | - Andrew M. Ryan
- Department of Urology, University of Michigan, Ann Arbor
| | - John M. Hollingsworth
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor
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3
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Katragadda C, Fung C, Yousefi-Nooraie R, Cupertino P, Joseph J, Kim Y, Li Y. Medicare accountable care organizations: post-acute care use and post-surgical outcomes in urologic cancer surgery. Urology 2022; 167:102-108. [PMID: 35772480 DOI: 10.1016/j.urology.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored. METHODS We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure. RESULTS Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes. CONCLUSIONS Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.
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Affiliation(s)
- Chinmayee Katragadda
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY.
| | - Chunkit Fung
- Division of Hematology, Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY; James P. Wilmot Cancer Institute, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Reza Yousefi-Nooraie
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Paula Cupertino
- James P. Wilmot Cancer Institute, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Jean Joseph
- Department of Urology, University of Rochester Medical Center, Rochester, NY
| | | | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
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4
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Baskin AS, Wang T, Miller J, Jagsi R, Kerr EA, Dossett LA. A Health Systems Ethical Framework for De-implementation in Health Care. J Surg Res 2021; 267:151-158. [PMID: 34153558 PMCID: PMC8678146 DOI: 10.1016/j.jss.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. METHODS To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. RESULTS AND DISCUSSION From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining "value," the proposed framework may increase the legitimacy and objectivity of de-implementation. CONCLUSIONS While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.
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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Reshma Jagsi
- Department of Radiation Oncology,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Eve A Kerr
- Department of Internal Medicine , Center for Clinical Management Research, Ann Arbor, MI
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
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Liao JM, Navathe AS, Werner RM. The Impact of Medicare's Alternative Payment Models on the Value of Care. Annu Rev Public Health 2021; 41:551-565. [PMID: 32237986 DOI: 10.1146/annurev-publhealth-040119-094327] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98195, USA; .,Value and Systems Science Lab, School of Medicine, University of Washington, Seattle, Washington 98195, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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6
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Neiman PU, Tsai TC, Bergmark RW, Ibrahim A, Nathan H, Scott JW. The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future. J Surg Res 2021; 263:102-109. [PMID: 33640844 DOI: 10.1016/j.jss.2020.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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Affiliation(s)
- Pooja U Neiman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Regan W Bergmark
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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7
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Paredes AZ, Hyer JM, Tsilimigras DI, Pawlik TM. Hepatopancreatic Surgery in the Rural United States: Variation in Outcomes at Critical Access Hospitals. J Surg Res 2021; 261:123-129. [PMID: 33422902 DOI: 10.1016/j.jss.2020.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/03/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. MATERIALS AND METHODS Medicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). RESULTS Patients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). CONCLUSIONS Only a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Hyer JM, Paredes AZ, Tsilimigras DI, Azap R, White S, Ejaz A, Pawlik TM. Preoperative continuity of care and its relationship with cost of hepatopancreatic surgery. Surgery 2020; 168:809-815. [DOI: 10.1016/j.surg.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 01/20/2023]
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Modi PK, Kaufman SR, Caram ME, Ryan AM, Shahinian VB, Hollenbeck BK. Medicare Accountable Care Organizations and the Adoption of New Surgical Technology. J Am Coll Surg 2020; 232:138-145.e2. [PMID: 33122038 DOI: 10.1016/j.jamcollsurg.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dissemination of new surgical technology is a major contributor to healthcare spending growth. Accountable care organization (ACO) policy aims to control spending while maintaining quality. As a result, ACOs provide incentive for hospitals to selectively adopt newer procedures with high value. STUDY DESIGN We conducted a retrospective cohort study using a 20% sample of national Medicare claims from 2010 to 2015. We identified hospitals that performed 1 of 6 sets of procedures: abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy or stent, lung lobectomy, colectomy, and prostatectomy. We identified hospitals participating in a Medicare Shared Savings Program ACO and a set of matched non-ACO control hospitals. We used a difference-in-differences approach to compare rate of surgical treatment and use of newer surgical technology for each set of procedures in ACO and non-ACO hospitals. RESULTS We included 707 ACO-hospitals and 1,770 control hospitals. ACO hospitals performed surgery for carotid stenosis at a lower rate than non-ACO hospitals. There was no difference in the rate of surgical treatment for all other procedure sets. ACO hospitals were less likely to use an endovascular approach for abdominal aortic aneurysm repair (85.2% vs 88.2%, p < 0.001) and more likely to use a minimally invasive approach for lung lobectomy (42.2% vs 34.7%, p = 0.004) than non-ACO hospitals. In difference-in-differences analysis, ACO participation was not associated with any significant difference in use of surgical care for any of the 6 procedure sets, nor with any significant difference in use of newer surgical technology. CONCLUSIONS Despite ACO policy incentives to selectively adopt newer surgical technology, ACO participation was not associated with differences in rate of surgery or use of newer surgical technology for 6 major surgical procedures.
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Affiliation(s)
- Parth K Modi
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan Ev Caram
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Andrew M Ryan
- Department of Medicine, University of Michigan Medical School and the Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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10
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Is Hospital Occupancy Rate Associated with Postoperative Outcomes Among Patients Undergoing Hepatopancreatic Surgery? Ann Surg 2020; 276:153-158. [DOI: 10.1097/sla.0000000000004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Modi PK, Moloci N, Herrel LA, Hollenbeck BK, Hollingsworth JM. Medicare Accountable Care Organizations Reduce Spending on Surgery. AMERICAN JOURNAL OF ACCOUNTABLE CARE 2020; 8:12-19. [PMID: 33073160 PMCID: PMC7561039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Surgical care among older adults is costly. While Medicare accountable care organizations (ACOs) are designed around primary care, there are reasons to believe that participation may also affect spending on surgery. This study examines the impact that Medicare ACO alignment has on spending for inpatient and outpatient surgical care. STUDY DESIGN We conducted a retrospective cohort study using national Medicare claims (2008 through 2015). Among a 20% random sample of beneficiaries, we identified adults 65 years of age and older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a Medicare ACO. We then measured payments for surgical services made on their behalf. Finally, we fit multivariable regression models to evaluate the association between ACO alignment and spending for inpatient and outpatient surgical care. RESULTS We identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with a Medicare ACO. After adjustment for patient factors, ACO alignment was associated with $181 [95% confidence interval (CI), -$243 to -$118; P <0.001] lower spending per beneficiary-year. ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year [incidence rate ratio (IRR), 0.97; 95% CI, 0.96 to 0.98; P <0.001] but 2.3% more outpatient episodes per year (IRR, 1.02; 95% CI, 1.02 to 1.03; P <0.001). Among inpatient surgical episodes, average payments were $956 lower for ACO aligned beneficiaries (95%CI -$1218 to -$694, P <0.001). CONCLUSIONS AND RELEVANCE ACO alignment was associated with savings on surgical care. These savings resulted from increased outpatient surgery and reduced use of inpatient surgery as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control healthcare spending.
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Affiliation(s)
- Parth K Modi
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Nicholas Moloci
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - John M Hollingsworth
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
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13
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Hyer JM, Ejaz A, Tsilimigras DI, Paredes AZ, Mehta R, Pawlik TM. Novel Machine Learning Approach to Identify Preoperative Risk Factors Associated With Super-Utilization of Medicare Expenditure Following Surgery. JAMA Surg 2020; 154:1014-1021. [PMID: 31411664 DOI: 10.1001/jamasurg.2019.2979] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Typically defined as the top 5% of health care users, super-utilizers are responsible for an estimated 40% to 55% of all health care costs. Little is known about which factors may be associated with increased risk of long-term postoperative super-utilization. Objective To identify clusters of patients with distinct constellations of clinical and comorbid patterns who may be associated with an elevated risk of super-utilization in the year following elective surgery. Design, Setting, and Participants A retrospective longitudinal cohort study of 1 049 160 patients who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, colectomy, total hip arthroplasty, total knee arthroplasty, or lung resection were identified from the 100% Medicare inpatient and outpatient Standard Analytic Files at all inpatient facilities performing 1 or more of the evaluated surgical procedures from 2013 to 2015. Data from 2012 to 2016 were used to evaluate expenditures in the year preceding and following surgery. Using a machine learning approach known as Logic Forest, comorbidities and interactions of comorbidities that put patients at an increased chance of becoming a super-utilizer were identified. All comorbidities, as defined by the Charlson (range, 0-24) and Elixhauser (range, 0-29) comorbidity indices, were used in the analysis. Higher scores indicated higher comorbidity burden. Data analysis was completed on November 16, 2018. Main Outcome and Measures Super-utilization of health care in the year following surgery. Results In total, 1 049 160 patients met inclusion criteria and were included in the analytic cohort. Their median (interquartile range) age was 73 (69-78) years, and approximately 40% were male. Super-utilizers comprised 4.8% of the overall cohort (n = 79 746) yet incurred 31.7% of the expenditures. Although the difference in overall expenditures per person between super-utilizers ($4049) and low users ($2148) was relatively modest prior to surgery, the difference in expenditures between super-utilizers ($79 698) vs low users ($2977) was marked in the year following surgery. Risk factors associated with super-utilization of health care included hemiplegia/paraplegia (odds ratio, 5.2; 95% CI, 4.4-6.2), weight loss (odds ratio, 3.5; 95% CI, 2.9-4.2), and congestive heart failure with chronic kidney disease stages I to IV (odds ratio, 3.4; 95% CI, 3.0-3.9). Conclusions and Relevance Super-utilizers comprised only a small fraction of the surgical population yet were responsible for a disproportionate amount of Medicare expenditure. Certain subpopulations were associated with super-utilization of health care following surgical intervention despite having lower overall use in the preoperative period.
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Affiliation(s)
- J Madison Hyer
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Anghela Z Paredes
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Rittal Mehta
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus.,Deputy Editor
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Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Farooq A, Mehta R, Wu L, Beal EW, White S, Endo I, Pawlik TM. Impact of Surgeon Volume on Outcomes and Expenditure Among Medicare Beneficiaries Undergoing Liver Resection: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 2020; 24:1520-1529. [PMID: 31325139 DOI: 10.1007/s11605-019-04323-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR). METHODS Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined. RESULTS Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055). CONCLUSION Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Ayesha Farooq
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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15
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Direct Contracting in Medicare. Ann Surg 2020; 271:632-634. [DOI: 10.1097/sla.0000000000003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Assessment of utilization efficiency using machine learning techniques: A study of heterogeneity in preoperative healthcare utilization among super-utilizers. Am J Surg 2020; 220:714-720. [PMID: 32008721 DOI: 10.1016/j.amjsurg.2020.01.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In the United States, 5% of patients represent up to 55% of all health care costs. This study sought to define healthcare utilization patterns among super-utilizers, as well as assess possible variation in patient outcomes. METHODS Medicare super-utilizers undergoing either a total hip or knee arthroplasty were identified and entered into a cluster analysis using annual preoperative charges to identify distinct patterns of utilization. RESULTS Among 19,522 super-utilizers who underwent THA or TKA, there was a marked heterogeneity in overall utilization with 5 distinct clusters of utilization patterns. Of note, comorbidity burden was similar among the 5 clusters. Patient outcomes also varied by Cluster type, ranging from 6.9% to 16.5% experiencing complications and 1.0%-3.2% experiencing 90-day mortality. CONCLUSION While previous studies have suggested that super-utilizers are a homogenous group of patients, the current study demonstrated a large degree of heterogeneity within super-utilizers. Variations in utilization patterns were associated with postoperative outcomes and subsequent health care costs.
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Sheetz KH, Nathan H. Methods for Enhancing Causal Inference in Observational Studies. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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18
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Can We Improve Prediction of Adverse Surgical Outcomes? Development of a Surgical Complexity Score Using a Novel Machine Learning Technique. J Am Coll Surg 2019; 230:43-52.e1. [PMID: 31672674 DOI: 10.1016/j.jamcollsurg.2019.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/15/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND An optimal method to quantify surgical complexity using patient comorbidities derived from administrative billing data is lacking. We sought to develop a novel, easy-to-use surgical Complexity Score to accurately predict adverse outcomes among patients undergoing elective surgery. STUDY DESIGN A novel surgical Complexity Score was developed using 100% Medicare Inpatient and Outpatient Standard Analytic Files (SAFs) from years 2012 to 2016 (n = 1,049,160). Comorbid conditions were entered into a machine learning algorithm to assign weights to maximize the correlation with multiple postoperative outcomes including morbidity, readmission, mortality, and postoperative super-use. Predictive ability was compared against 3 of the most commonly used risk adjustment indices: the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), and the Centers for Medicare and Medicaid Service's Hierarchical Condition Category (CMS-HCC). RESULTS Patients underwent colectomy (12.6%), abdominal aortic aneurysm repair (4.4%), coronary artery bypass grafting (13.0%), total hip replacement (22.0%), total knee replacement (43.0%), or lung resection (5.0%). The Complexity Score had a good to very good predictive ability for all adverse outcomes. The Complexity Score had the highest accuracy in predicting perioperative morbidity (area under the curve [AUC]: 0.868, 95% CI 0.866 to 0.869); this performed better than the CCI (AUC: 0.717, 95% CI 0.715 to 0.719), ECI (AUC: 0.799, 95% CI 0.797 to 0.800), and similar to the CMS-HCC (AUC: 0.862, 95% CI 0.861 to 0.863). Similarly, the Complexity Score outperformed each of the 3 other comorbidity indices in predicting 90-day readmission (AUC: 0.707, 95% CI 0.705 to 0.709), 30-day readmission (AUC: 0.717, 95% CI 0.715 to 0.720), and postoperative super-use (AUC: 0.817, 95% CI 0.814 to 0.820). CONCLUSIONS Compared with the most commonly used comorbidity and surgical risk scores, the novel surgical Complexity Score outperformed the CCI, ECI, and CMS-HCC in predicting postoperative morbidity, 30-day readmission, 90-day readmission, and postoperative super-use.
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Bae J, Hyer JM, Paredes AZ, Farooq A, Rice DR, White S, Tsilimigras DI, Ejaz A, Pawlik TM. Evaluation of costs and outcomes of physician-owned hospitals across common surgical procedures. Am J Surg 2019; 220:120-126. [PMID: 31619377 DOI: 10.1016/j.amjsurg.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The Affordable Care Act introduced restrictions on the creation of new physician-owned hospitals (POH). We sought to define whether POH status was associated with differences in care. METHODS Patients undergoing one of ten surgical procedures were identified using Medicare Standard Analytic Files. Patient and hospital-level characteristics and outcomes between POH and non-POH were compared. RESULTS Among 1,255,442 patients identified, 14,560 (1.2%) were treated at POH. A majority of POHs were in urban areas (n = 30, 90.9%) and none were in low socioeconomic status areas. Patients at POH were slightly younger (POH:72, IQR:68-77 vs. non-POH:73, IQR:69-79) and healthier (CCI; POH:2; IQR: 1-3 vs. non-POH: 3; IQR: 1-4). Patients at non-POH had higher odds of postoperative complications (OR:1.67, 95%CI:1.55-1.80) and slightly higher medical expenditures (POH:$11,347, IQR:$11,139-$11,936 vs. non-POH:$13,389, IQR:$11,381-$19,592). CONCLUSIONS POH were more likely to be located in socioeconomic advantaged areas, treat healthier patients and have lower associated expenditures.
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Affiliation(s)
- Junu Bae
- Ohio State University College of Medicine, Columbus, OH, USA; Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ayesha Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Daniel R Rice
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Is Annual Preoperative Utilization an Indicator of Postoperative Surgical Outcomes? A Study in Medicare Expenditure. World J Surg 2019; 44:108-114. [PMID: 31531723 DOI: 10.1007/s00268-019-05184-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Data on the association of high preoperative healthcare utilization and adverse clinical outcomes are scarce. We sought to evaluate the role of annual preoperative expenditure (APE) as a surrogate for latent variables of risk for adverse short-term postoperative outcomes. METHODS Low and super-utilizers who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, colectomy, total hip arthroplasty, total knee arthroplasty, or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files. To assess the association between APE and postoperative outcomes, multivariable logistic regression was utilized. RESULTS Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were preoperative low- and super-utilizers, respectively. Median APE was more than 60 times higher among super-utilizers than low-utilizers ($57,160 vs. $932), as was the cost of the surgical episode ($21,141 vs. $13,179). The predictive ability of APE ranged from 0.683 (95% CI 0.678-0.687) for 90-day readmission to 0.882 (95% CI 0.879-0.886) for a complication at the index hospitalization. Among super-utilizers, the odds of a complication during the surgical episode was nearly double versus low-utilizers (OR = 1.96, 95% CI 1.89-2.04). Super-utilizers also had an increased odds of 30-day readmission (OR = 1.64, 95% CI 1.58-1.69) and mortality (OR = 2.22; 95% CI 2.04-2.42). CONCLUSION APE was able to predict adverse postsurgical outcomes including complications during the surgical episode, readmission, and 90-day mortality. APE should be considered in the assessment of patient populations when defining risk of adverse postoperative events.
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Liao JM, Emanuel EJ, Venkataramani AS, Huang Q, Dinh CT, Shan EZ, Wang E, Zhu J, Cousins DS, Navathe AS. Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations. JAMA Netw Open 2019; 2:e1912270. [PMID: 31560389 PMCID: PMC6777392 DOI: 10.1001/jamanetworkopen.2019.12270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
Importance An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures Changes in clinical outcomes and mean LEJR episode spending. Results A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire T. Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric Z. Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Lipa SA, Blucher JA, Sturgeon DJ, Harris MB, Schoenfeld AJ. Changes in healthcare delivery following spinal fracture in Medicare Accountable Care Organizations. Spine J 2019; 19:1340-1345. [PMID: 31009769 DOI: 10.1016/j.spinee.2019.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Accountable Care Organizations (ACOs) were designed to reduce healthcare costs while simultaneously improving quality. Given that the success of ACOs is predicated on controlling costs, concerns have been expressed that patients could be adversely affected through restricted access to surgery, including in the context of spine fracture care. PURPOSE Evaluate the impact of Medicare ACO formation on the utilization of surgery and outcomes following spinal fractures. STUDY DESIGN Retrospective review of Medicare claims (2009-2014). PATIENT SAMPLE Patients treated for spinal fractures in an ACO or non-ACO. OUTCOME MEASURES The utilization of surgery as treatment for spinal fractures, in-hospital mortality, 90-day complications, or hospital readmission within 90-days injury. METHODS We used a pre-post study design to compare outcomes for patients treated in ACOs versus non-ACOs. Receipt of surgery for treatment of a spinal fracture was the primary outcome, with mortality, complications and readmissions treated secondarily. We used multivariable logistic regression adjusting for confounders to determine the association between environment of care (ACO vs. non-ACO) and the outcomes of interest. In all testing, beneficiaries treated in non-ACOs during 2009 to 2011 were used as the referent. RESULTS During 2009 to 2011, 9% (n=10,866) of patients treated in non-ACOs received surgery, whereas a similar percentage (9%; n=210) underwent surgery in ACOs. This figure decreased to 8% (n=9,857) for individuals treated in non-ACOs over 2012 to 2014, although the surgical rate remained unchanged for those receiving care in an ACO (9%; n=227). There was no difference in the use of surgery among patients treated in ACOs (OR 0.96; 95% CI 0.79, 1.18) over 2012 to 2014. Similar increases in the odds of mortality were observed for both ACOs and non-ACOs during this period. A marginal, yet significant increase in complications was observed among ACOs, although there was no change in the odds of readmission. CONCLUSIONS Our study found that the formation of ACOs did not result in alterations in the use of surgery for spinal fractures or substantive changes in outcomes. As ACOs continue to evolve, more emphasis should be placed on the incorporation of measures directly related to surgical and trauma care in the determinants of risk-based reimbursements.
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Affiliation(s)
- Shaina A Lipa
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel J Sturgeon
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02214, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Mehta R, Sahara K, White S, Dillhoff ME, Ejaz A, Cloyd JM, Pawlik TM. Hospice utilization among Medicare beneficiaries dying from pancreatic cancer. J Surg Oncol 2019; 120:624-631. [PMID: 31290170 DOI: 10.1002/jso.25623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/21/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Use of hospice services among patients with pancreatic cancer following pancreatic resection remains unknown. METHODS Patients with pancreatic cancer who underwent resection were identified in the Medicare Standard Analytic Files. Outcomes included overall hospice use, early hospice enrollment (≥4 weeks before death), late hospice enrollment (initiation within 3 days of death), and Medicare expenditures. RESULTS Among the 4369 deceased individuals, three-fourths of patients (n = 3252, 74.4%) used hospice at the time of death. Patients who did not use hospice were more likely to be male, have a complication on index admission and receive life sustaining treatments on subsequent admissions (P < .05). Only one-third (32.2%) of patients initiated hospice services early. Medicare expenditure during the last month of life was $10 000 lower among patients who initialized hospice services at least 1 month before death versus within 3 days of death (late: $10 581 [$5454-$17 200], early: $221 [$46-$733]; P < .001) CONCLUSION: While three-fourths of patients utilized hospice services after pancreatic resection, only one-third of patients initiated hospice services at least one-month before death. Late hospice use was associated with higher Medicare expenditures during the last month of life. Further research is needed to understand barriers to early hospice utilization.
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Affiliation(s)
- Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Susan White
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.,Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Characterizing and Assessing the Impact of Surgery on Healthcare Spending Among Medicare Enrolled Preoperative Super-utilizers. Ann Surg 2019; 270:554-563. [DOI: 10.1097/sla.0000000000003426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Reames BN, Anaya DA, Are C. Hospital Regional Network Formation and 'Brand Sharing': Appearances May Be Deceiving. Ann Surg Oncol 2019; 26:711-713. [PMID: 30607763 DOI: 10.1245/s10434-018-07129-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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Hospital Costs Related to Early Extubation After Infant Cardiac Surgery. Ann Thorac Surg 2018; 107:1421-1426. [PMID: 30458158 DOI: 10.1016/j.athoracsur.2018.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/25/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation rates after infant tetralogy of Fallot (TOF) and coarctation of the aorta (CoA) repair across participating sites by implementing a clinical practice guideline (CPG). The impact of the CPG on hospital costs has not been studied. METHODS PHN CLS clinical data were linked to cost data from Children's Hospital Association by matching on indirect identifiers. Hospital costs were evaluated across active and control sites in the pre- and post-CPG periods using generalized linear mixed-effects models. A difference-in-difference approach was used to assess whether changes in cost observed in active sites were beyond secular trends in control sites. RESULTS Data were successfully linked on 410 of 428 eligible patients (96%) from four active and four control sites. Mean adjusted cost per case for TOF repair was significantly reduced in the post-CPG period at active sites ($42,833 vs $56,304, p < 0.01) and unchanged at control sites ($47,007 vs $46,476, p = 0.91), with an overall cost reduction of 27% in active versus control sites (p = 0.03). Specific categories of cost reduced in the TOF cohort included clinical (-66%, p < 0.01), pharmacy (-46%, p = 0.04), lab (-44%, p < 0.01), and imaging (-32%, p < 0.01). There was no change in costs for CoA repair at active or control sites. CONCLUSIONS The early extubation CPG was associated with a reduction in hospital costs for infants undergoing repair of TOF but not CoA. This CPG represents an opportunity to both optimize clinical outcome and reduce costs for certain infant cardiac surgeries.
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Achieving High-value Surgical Care Through Accountable Care Organizations: Are the Risks Worth the Rewards? Ann Surg 2018; 269:197-198. [PMID: 30312206 DOI: 10.1097/sla.0000000000003070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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