Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

Health Care Value in Plastic Surgery Practice

SUMMARY

As value-based care gains traction in response to towering health care expenditures and issues of health care inequity, hospital capacity, and labor shortages, it is important to consider how a value-based approach can be achieved in plastic surgery. Value is defined as outcomes divided by costs across entire cycles of care. Drawing on previous studies and policies, this article identifies key opportunities in plastic surgery to move the levers of costs and outcomes to deliver higher value care. Specifically, outcomes in plastic surgery should include conventional measures of complication rates and patient-reported outcome measures to drive quality improvement and benchmark payments. Meanwhile, cost reduction in plastic surgery can be achieved through value-based payment reform, efficient workflows, evidence-based and cost-conscious selection of medical devices, and greater use of outpatient surgical facilities. Lastly, the authors discuss how the diminished presence of third-party payers in aesthetic surgery exemplifies the cost-conscious and patient-centered nature of value-based plastic surgery. To lead in future health policy and care delivery reform, plastic surgeons should strive for high-value care, remain open to new ways of care delivery, and understand how plastic surgery fits into overall health care delivery.

The Correlation of Surgical Setting With Perioperative Opioid Prescriptions for Wide-Awake Carpal Tunnel Release

BACKGROUND

Prior studies have compared perioperative opioid prescriptions between carpal tunnel release (CTR) performed wide-awake and with traditional anesthetic techniques, but the association of opioid prescriptions with surgical setting has not been fully explored. The current study assessed the association of opioid prescriptions with surgical setting (office or operating room) for wide-awake CTR.

METHODS

Patients with open CTR were identified in an administrative claims database (PearlDiver). Exclusion criteria included age less than 18 years, preoperative data less than 6 months, postoperative data less than 1 month, bilateral surgery, concomitant hand surgery, and traditional anesthesia (general anesthesia, sedation, or regional block). Patients were stratified by surgical setting (office or operating room) and matched by age, sex, Elixhauser Comorbidity Index, and geographic region. Prior opioid prescriptions, opioid dependence/abuse, substance use disorder, back/neck pain, generalized anxiety, and major depression were identified. Opioid prescriptions within 7 days before and 30 days after surgery were characterized.

RESULTS

Each matched cohort included 5713 patients. Compared with patients with surgery in the operating room, fewer patients with office-based surgery filled opioid prescriptions (45% vs 62%), and those prescriptions had lower morphine milligram equivalents (MMEs, median 130 vs 188). These findings were statistically significant on univariate and multivariate analysis.

CONCLUSIONS

Following office-based CTR, fewer patients filled opioid prescriptions, and filled prescriptions had lower MME. This likely reflects patient and provider attitudes about pain control and opioid utilization. Further patient- and provider-level investigation may provide additional insights that could aid in efforts to reduce perioperative opioid utilization across surgical settings.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty

BACKGROUND

With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care.

METHODS

A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service.

RESULTS

From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans.

CONCLUSION

From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Office-based anesthesia: a contemporary update on outcomes, incentives, and controversies

PURPOSE OF REVIEW

The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies.

RECENT FINDINGS

Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates.

SUMMARY

The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery.

Catastrophic Health Expenditures Associated With Open Reduction Internal Fixation of Distal Radius Fractures

PURPOSE

Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE.

METHODS

We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE.

RESULTS

In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients.

CONCLUSIONS

Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis II.

The Influence of Out-of-Pocket Cost on Wrist Fracture Treatment Selection

PURPOSE

Patient-centered care prioritizes patients' specific health needs and desired outcomes based on their preferences, values, and goals. The aim of this study was to evaluate nonclinical factors that affect decision-making related to wrist fracture treatment options.

METHODS

A discrete choice experiment was administered via Amazon Mechanical Turk. Participants chose between two treatment options for theoretical wrist fractures. Each choice set contained three levels for four attributes-total out-of-pocket cost, length of cast immobilization, time to return to work, and number of posttreatment follow-up visits-determined using Medicare national average out-of-pocket costs and a range of standard treatment options. Financial stress was evaluated using the InCharge Financial Distress/Financial Well-Being Scale.

RESULTS

A total of 232 responses were collected. The average financial stress score was 6.29 (SD, 1.97), with 22% (52/232) being classified as financially distressed (score < 5.00). Twenty-eight percent of the participants (n = 64) always chose the lowest cost option, and two participants (0.01%) always chose less time in a cast. Over one-third of the participants chose the cheaper monetary option 80% of the time or more. The odds of choosing a lower cost option were 1.06 times greater per $100 decrease in cost in the entire cohort and 1.03 times greater among 166 participants who did not always choose the least expensive option. In monetary terms, relative importance showed that the participants were willing to pay $19.48 and $58.37 for a week less of cast immobilization and out of work, respectively.

CONCLUSIONS

This study demonstrates the important role that out-of-pocket cost plays in decision-making compared with the nonclinical components of two equivalent treatment options.

CLINICAL RELEVANCE

Providers should be cognizant of the cost associated with treatment options so that information on treatment cost can be incorporated into counseling and shared decision-making with patients undergoing hand surgery.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury

PURPOSE

Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery.

METHODS

Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis.

RESULTS

Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE.

CONCLUSIONS

Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery.

CLINICAL RELEVANCE

Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Identifying High Direct Variable Costs of Open Carpal Tunnel Release Patients Using Time-Driven Activity-Based Costing

PURPOSE

To improve value in health care delivery, a deeper understanding of the cost drivers in hand surgery is necessary. Time-driven activity-based costing (TDABC) more accurately reflects true resource use compared with traditional accounting methods. This study used TDABC to explore the facility cost of carpal tunnel release and identify preoperative characteristics of high-cost patients.

METHODS

Using TDABC, we calculated the facility costs of 516 consecutive patients undergoing open carpal tunnel release at an orthopedic specialty hospital between 2015 and 2021. Patients in the top decile cost were defined as high-cost patients. Multivariable logistic regression was used to determine preoperative characteristics (age, sex, body mass index, race, ethnicity, Elixhauser comorbidity index, American Society of Anesthesiology score, preoperative Disabilities of the Arm, Shoulder and Hand score, Short-Form 12, and anesthesia type) independently associated with high-cost patients.

RESULTS

Surgery-related personnel costs were the main driver (38.0%) of total facility costs, followed by preoperative personnel costs (21.3%). There was a 1.8-fold variation in facility cost between patients in the 90th and 10th percentiles ($774.69 vs $431.35), with the widest cost variations belonging to medication costs ($17.67 vs $1.85; variation, 9.6-fold) and other supply costs ($213.56 vs $65.56; variation, 3.3-fold). Using multivariable regression, predictors of high cost were patient age and use of general anesthesia. Total facility costs correlated strongly with the total operating room time and incision to closure time.

CONCLUSIONS

Efforts to decrease operating room time may translate into reduced personnel costs and greater cost savings. Multidisciplinary initiatives to control medication expenses for patients at risk of high costs may narrow the existing variation in costs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis II.