1
|
Folguera J, Buj E, Monterde D, Carot-Sans G, Cano I, Piera-Jiménez J, Arrufat M. Retrospective analysis of hospitalization costs using two payment systems: the diagnosis related groups (DRG) and the Queralt system, a newly developed case-mix tool for hospitalized patients. HEALTH ECONOMICS REVIEW 2024; 14:45. [PMID: 38922476 PMCID: PMC11202329 DOI: 10.1186/s13561-024-00522-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 06/14/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Hospital services are typically reimbursed using case-mix tools that group patients according to diagnoses and procedures. We recently developed a case-mix tool (i.e., the Queralt system) aimed at supporting clinicians in patient management. In this study, we compared the performance of a broadly used tool (i.e., the APR-DRG) with the Queralt system. METHODS Retrospective analysis of all admissions occurred in any of the eight hospitals of the Catalan Institute of Health (i.e., approximately, 30% of all hospitalizations in Catalonia) during 2019. Costs were retrieved from a full cost accounting. Electronic health records were used to calculate the APR-DRG group and the Queralt index, and its different sub-indices for diagnoses (main diagnosis, comorbidities on admission, andcomplications occurred during hospital stay) and procedures (main and secondary procedures). The primary objective was the predictive capacity of the tools; we also investigated efficiency and within-group homogeneity. RESULTS The analysis included 166,837 hospitalization episodes, with a mean cost of € 4,935 (median 2,616; interquartile range 1,011-5,543). The components of the Queralt system had higher efficiency (i.e., the percentage of costs and hospitalizations covered by increasing percentages of groups from each case-mix tool) and lower heterogeneity. The logistic model for predicting costs at pre-stablished thresholds (i.e., 80th, 90th, and 95th percentiles) showed better performance for the Queralt system, particularly when combining diagnoses and procedures (DP): the area under the receiver operating characteristics curve for the 80th, 90th, 95th cost percentiles were 0.904, 0.882, and 0.863 for the APR-DRG, and 0.958, 0.945, and 0.928 for the Queralt DP; the corresponding values of area under the precision-recall curve were 0.522, 0.604, and 0.699 for the APR-DRG, and 0.748, 0.7966, and 0.834 for the Queralt DP. Likewise, the linear model for predicting the actual cost fitted better in the case of the Queralt system. CONCLUSIONS The Queralt system, originally developed to predict hospital outcomes, has good performance and efficiency for predicting hospitalization costs.
Collapse
Affiliation(s)
- Júlia Folguera
- Catalan Health Service, Gran Via de les Corts Catalanes 587, Barcelona, 08007, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3) - Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, Spain
| | | | - David Monterde
- Digitalization for the Sustainability of the Healthcare System (DS3) - Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, Spain
- Catalan Institute of Health, Barcelona, Spain
| | - Gerard Carot-Sans
- Catalan Health Service, Gran Via de les Corts Catalanes 587, Barcelona, 08007, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3) - Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, Spain
| | - Isaac Cano
- Fundació de Recerca Clinic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB- IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Piera-Jiménez
- Catalan Health Service, Gran Via de les Corts Catalanes 587, Barcelona, 08007, Spain.
- Digitalization for the Sustainability of the Healthcare System (DS3) - Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, Spain.
- Faculty of Informatics, Telecommunications and Multimedia, Universitat Oberta de Catalunya, Barcelona, Spain.
| | | |
Collapse
|
2
|
Badin D, Ortiz-Babilonia C, Musharbash FN, Jain A. Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review. Global Spine J 2023; 13:534-546. [PMID: 35658589 PMCID: PMC9972279 DOI: 10.1177/21925682221103530] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF). METHODS Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes. RESULTS A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories. CONCLUSIONS In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.
Collapse
Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | | | - Farah N. Musharbash
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA,Amit Jain, MD, Department of Orthopaedic
Surgery, Johns Hopkins University, 601 N Caroline St, JHOC 5230 Baltimore, MD
21287, USA.
| |
Collapse
|
3
|
Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2022; 47:1701-1709. [PMID: 35960599 DOI: 10.1097/brs.0000000000004455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVES The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race. SUMMARY OF BACKGROUND DATA Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF. MATERIALS AND METHODS The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics. RESULTS Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (β=3.09, P =0.036) and ∆NDI (β=-7.32, P =0.003). CONCLUSIONS All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients. LEVEL OF EVIDENCE 3.
Collapse
|
4
|
Lopez CD, Boddapati V, Neuwirth AL, Shah RP, Cooper HJ, Geller JA. Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty. Arthroplast Today 2020; 6:437-444. [PMID: 32613050 PMCID: PMC7320234 DOI: 10.1016/j.artd.2020.04.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Over 1 million total joint arthroplasties (TJAs) are performed every year in the United States, creating Medicare cost concerns for policy makers. The purpose of this study is to evaluate recent trends in Medicare utilization and reimbursements to hospitals/surgeons for TJAs between 2012 and 2017. METHODS We tracked annual Medicare claims and payments to TJA surgeons using publicly available Medicare databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization (per 10,000 Medicare beneficiaries), and reimbursement rates and to examine associations between county-specific variables and TJA utilization and reimbursements. RESULTS Between 2012 and 2017, there was an 18.9% increase in annual primary TJA volume (357,500 cases in 2012 to 425,028 cases in 2017) and a 2.0% increase in annual primary TJA per capita utilization (73.4 cases per 10,000 Medicare beneficiaries in 2012 to 74.8 in 2017). The Midwest and the South had higher utilization rates compared with the Northeast and West (P < .001). Utilization rates for primary TJA procedures also had a significant negative association with the poverty rate (P < .001). Medicare Part B payments to surgeons fell by 7.5%, equivalent to a 14.9% inflation-adjusted decline, whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively, during the study period. CONCLUSIONS Despite increasing TJA volume and utilization, surgeon reimbursements have continued to decline, whereas hospital payments and hospital charges have increased significantly more than surgeon charges. Cost containment efforts will need to address other expenditures such as hospital costs and implant costs to better align financial risks and incentives for TJA surgeons.
Collapse
Affiliation(s)
- Cesar D. Lopez
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander L. Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshan P. Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - H. John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey A. Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
5
|
Associated risk factors for extended length of stay following anterior cervical discectomy and fusion for cervical spondylotic myelopathy. Clin Neurol Neurosurg 2020; 195:105883. [DOI: 10.1016/j.clineuro.2020.105883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/27/2022]
|
6
|
Ranson WA, Neifert SN, Cheung ZB, Mikhail CM, Caridi JM, Cho SK. Predicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices. World Neurosurg 2019; 134:e487-e496. [PMID: 31669536 DOI: 10.1016/j.wneu.2019.10.102] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to determine the ability of the Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) to predict postoperative complications after anterior cervical discectomy and fusion (ACDF). METHODS This was a retrospective study of ACDF hospitalizations in the National Inpatient Sample from 2013 to 2014. The ECI and CCI were calculated, and patients who experienced postoperative complications were identified. The ability of these indexes to predict complications was compared using the c statistic (area under the receiver operating characteristic curve [AUC]). In addition, the CCI and ECI were compared with a base model that included age, sex, race, and primary payer. RESULTS A total of 261,780 patients were included. Patients who experienced a complication were more often male (P < 0.0001) and older (P < 0.0001). They also had a higher comorbidity burden as assessed by both the ECI (P < 0.0001) and the CCI (P < 0.0001). The ECI was superior in predicting airway complications (AUC, 0.81 vs. 0.75; P < 0.0001), hemorrhagic anemia (AUC, 0.67 vs. 0.63; P = 0.0015), pulmonary embolism (AUC, 0.91 vs. 0.77; P < 0.0001), wound dehiscence (AUC, 0.80 vs. 0.55; P = 0.0080), sepsis (AUC, 0.87 vs. 0.82; P = 0.0001), and septic shock (AUC, 0.94 vs. 0.83; P < 0.0001). The CCI was not found to be superior to the ECI for predicting any complications. Both were excellent for predicting mortality (ECI AUC, 0.87; CCI AUC, 0.90). CONCLUSIONS The ECI was superior to the CCI in predicting 6 of 15 complications in this study. Both are excellent tools for predicting mortality after ACDF.
Collapse
Affiliation(s)
- William A Ranson
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | | | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA.
| |
Collapse
|
7
|
Lyons KW, Klare CM, Kunkel ST, Lemire JR, Bao M, McGuire KJ, Pearson AM, Abdu WA. A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis. Int J Spine Surg 2019; 13:378-385. [PMID: 31531288 DOI: 10.14444/6052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. Methods A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. Results Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively. Conclusions As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly. Clinical Relevance Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.
Collapse
Affiliation(s)
- Keith W Lyons
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Christian M Klare
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Samuel T Kunkel
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Jason R Lemire
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Mike Bao
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Kevin J McGuire
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - Adam M Pearson
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| | - William A Abdu
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire
| |
Collapse
|