San Juan J et al, 2017: Variation in Spending around Surgical Episodes of Urinary Stone Disease-Findings from Michigan.
San Juan J, Hou H, Ghani KR, Dupree JM, Hollingsworth JM.
Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan.
PURPOSE: To help rein in surgical spending, there is growing interest in the application of payment bundles to common outpatient procedures like ureteroscopy (URS) and shockwave lithotripsy (SWL). However, before urologists can move to such a payment system, they need to know where their episode costs are concentrated.
MATERIALS AND METHODS: Using claims data from the Michigan Value Collaborative, we identified patients who underwent URS or SWL at hospitals in Michigan (2012 to 2015). We then totaled expenditures for all relevant services during these patients' 30-day surgical episodes and categorized component payments [i.e., those for the index procedure, subsequent hospitalizations, professional services, and post-acute care (PAC)]. Finally, we quantified variation in total episode expenditures for URS and SWL across hospitals, examining drivers of this variation.
RESULTS: In total, 9,449 URS and 6,446 SWL procedures were performed at 62 hospitals. Among these hospitals, there was three-fold variation in URS and SWL spending. The index procedure accounted for the largest payment difference between high- and low-cost hospitals (URS: $7,936 vs. $4,995, P<0.01; SWL: $4,832 vs. $3,207, P<0.01), followed by payments for PAC (URS: $2,207 vs. $1,711, P<0.01; SWL: $2,138 vs. $1,104, P<0.01). The index procedure explained 68% and 44%, and PAC payments explained 15% and 28% of the variation in episode spending for URS and SWL, respectively, across hospitals. CONCLUSIONS: There exists substantial variation in ambulatory surgical spending across Michigan hospitals for urinary stone episodes, most of which can be explained by payment differences for the index procedure and PAC services.
J Urol. 2017 Nov 24. pii: S0022-5347(17)77983-9. doi: 10.1016/j.juro.2017.11.075. [Epub ahead of print]. FREE ARTICLE
This economic analysis is based on data from a large number of hospitals in the Michigan area.
The recorded payment for the index patient varied considerably but was higher for patients treated with URS than for those treated with SWL. There was approximately similar spending on acute care after the two procedures.
The results are discussed by the authors and the advantages and disadvantages of bundled payments considered. It is important to note that such a system requires correct coding of the surgical treatment.
My personal view is that in the computer-era, the payment should be based on detailed costs for every procedure that has been carried out. Such a system, however, needs patient files that in a standardized way account for every individual cost.