T. C. Tsai1,2, F. Greaves2, E. J. Orav3,4, M. Zinner1, A. Jha2,3 1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA
Introduction: The rise of new payment models, such as bundled payments after major surgical procedures, has led policymakers and clinical leaders to increase their focus on episodes of care. Despite interest in this area, we know little about how much longer-term costs vary after major procedures and whether high quality surgical hospitals, those with high performance on process measures or patient experience, have lower long-term costs after procedures. Therefore, we examined variations in long-term costs after major procedures, the relationship between key structural factors and Medicare costs, and assessed if higher quality hospitals had higher costs.
Methods: Using 2011 national Medicare 20% claims files, we calculated episodes of care associated with an index admission and 30 and 90 of post-discharge care for patients undergoing coronary artery bypass graft, pulmonary lobectomy, abdominal aortic aneurysm repair, colectomy, and hip replacement. All Medicare payments were standardized to national fee-schedules to allow for national comparisons. Our main predictors of quality were hospital patient satisfaction as measured by the HCAHPS survey and hospital perioperative mortality. We used bivariate and multivariate models adjusting for case-mix to assess the relationship between hospital characteristics, quality, and long-term costs.
Results: We identified 51,249 patients. Average 30-day spending was $32,514. While spending on the index admission was the largest component of the episode, spending on post-acute care had the largest variation, varying from $2,998 for endovascular abdominal aortic aneurysm repair to $9,667 for hip replacement. Patients who went to hospitals with low satisfaction resulted in $2,626 more in spending than patients who went to hospitals with high satisfaction ($36,637 vs. $34,011, p<0.001). Similarly, patients receiving care at hospitals with high mortality resulted in $1,890 more in spending than patients who went to hospitals with low mortality ($38,952 vs. $34,062, p<0.001). Patterns were consistent for 90 days. Spending on post-acute care accounted for the largest variation in spending between high and low quality hospitals (59%).
Conclusion: Elderly patients receiving surgical care at low-quality hospitals result in higher spending than patients receiving care at high quality hospitals, and these patterns persisted out to 90-days. Post-acute care accounted for the largest variation in spending between high and low-quality hospitals. Because low-quality surgical care represents a serious cost to Medicare over the course of an episode, policies such as bundled payments may serve as an important step to aligning cost and quality for surgical care.