S. P. Shubeck1,5,6, A. H. Cain-Nielsen1, E. Norton2,3,4, S. Regenbogen1,5 2University Of Michigan,Department Of Health Management,Ann Arbor, MI, USA 3University Of Michigan,Department Of Economics,Ann Arbor, MI, USA 4National Bureau Of Economic Research,Cambridge, MA, USA 5University Of Michigan,Center For Health Outcomes & Policy (CHOP),Ann Arbor, MI, USA 6University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA
Introduction: As payment for inpatient surgery transitions to bundled payments for surgical episodes, hospitals face increasing pressure to reduce utilization in and out of hospital. We previously found that early routine postoperative discharge after major surgery incurred lower total episode payments without compensatory increase in post-discharge expenditures. Whether this strategy can succeed for older patients and those with higher levels of comorbidity is unknown.
Methods: We evaluated a cross-sectional cohort of 189,229 Medicare beneficiaries 65 or older undergoing colectomy 2009-2012 and computed associations between episode payments and hospitals’ length of stay (LOS) stratified by patients’ age and health status, according to the Elixhauser Comorbidity Index. Hospitals’ LOS was characterized by the mode to reflect typical hospital practice and minimize the influence of outliers. To focus on patients adhering to hospitals’ typical care, we then restricted analysis to the 73,212 patients discharged within one day of the mode LOS for each hospital. In this cohort, we evaluated risk-adjusted, price-standardized 90-day overall episode payments including index hospitalization, outlier payments, unplanned readmissions, professional services, and post-acute care.
Results: Total episode payments were lower in shortest LOS than longest LOS hospitals in all age categories (65-69: $33,084 vs. $41,006; >=80 $32,239 vs. $42,526; both p<0.001). The oldest patients had greater post-discharge care expenditures than youngest patients, but the disparity was similar in shortest and longest LOS hospitals (+$289 vs +$1,275, p=0.20). Conversely, patients with greatest comorbidity had no reduction in total episode payments in shortest LOS hospitals ($42,848 for 3 day LOS vs. $44,647 in >=7 day LOS, p=0.06, figure). The increase in post-discharge care expenditures for patients with highest comorbidity was greater in shortest versus longest LOS hospitals (+$4,101 vs. +$1,863, p=0.002).
Conclusion: Even the oldest Medicare beneficiaries experience lower total episode payments without compensatory increase in post-acute care expenditures when undergoing colectomy in hospitals with shortest post-operative LOS pathways. In contrast, those with greatest comorbiditiy accrue no savings in short LOS hospitals as they require more post-acute care services to achieve early discharge. These findings suggest that payment reform and initiatives to improve the efficiency of perioperative care must consider overall health status more than age alone.
