Surgonomics: the identifier concept. Hospital charges in general surgery and surgical specialties under prospective payment systems.

Surgical care is entering a new payment era for inhospital care using the diagnostic related group (DRG) mechanism for Medicare. A study at The Long Island Jewish-Hillside Medical Center showed that a majority of its surgical DRGs would be unprofitable under the proposed reimbursement scheme. This study was undertaken to develop a method of allowing the hospital to group patients with each DRG that would show a difference in hospital charges and be clinically meaningful to surgeons. The study implementors tested the hypothesis that entities called identifiers, arbitrarily chosen as mode of admission [emergency (+ER vs. nonemergency (-ER)] and presence (+T) or absence (-T) of blood transfusion, would show a difference in charges (mean hospital charge exclusive of physician fees) within a DRG. Nine hundred five patients in nine DRGs encompassing general surgery, thoracic surgery, cardiac surgery, neurosurgery, orthopedics, urology, and head and neck surgery were studied. For ER identifier, eight of nine DRGs were found to be positive (greater than 20% difference in charges between positive and negative identifier); for T identifier, all DRGs (9) were positive. These findings demonstrate that these identifiers may enable teaching institutions to disaggregate each DRG and, in this way, propose more equitable reimbursement rates.     

Surgonomics: the cost of cholecystectomy

Health care costs presently comprise more than one tenth of the nation's gross national product: One third of these expenditures are made by Medicare-Medicaid. National reimbursement changes for Medicare under a Diagnostic-Related Group system began October 1, 1983. Hospital charges (excluding physician charges) for all patients who underwent cholecystectomy without common bile duct exploration (Diagnostic-Related group 197 and 198) from Jan. 1, 1983 to March 31, 1983 were examined to quantify mean charges, variances, and components of hospital charges. Twenty-one patients (mean age 46.1 years) underwent elective cholecystectomy and 24 patients (mean age 64.9 years) underwent emergency cholecystectomy. The mean charge for elective cholecystectomy was $4763 +/- $1656; the mean length of stay (LOS) was 8.0 +/- 3.2 days. Low and high trim points were $3211 to $10,639 and 5 to 19 days LOS. Quartile cost analysis of the cost per patient showed that Q1 = 18.5%, Q2 = 21.2%, Q3 = 24.0%, and Q4 = 36.3%. Analysis of services showed that laboratory work (urinalysis, hematology, coagulation, microbiology, and biochemistry) averaged $451 +/- $298 (9.5% of total), room and board $2635 +/- $1044 (55.3% of total), operating and recovery room $924 +/- $167 (19.4% of total), and central supply-pharmacy $350 +/- $158 (7.4% of total). The mean charge for patients undergoing emergency cholecystectomy was $11,436 +/- $4185; mean LOS was 17.8 +/- 6.5 days. Low and high trim points were $6353 to $19,734; LOS was 9 to 30 days. Services as percent of total were laboratory 15.8%, room and board 53.7%, operating and recovery room 9.14%, central supply-pharmacy 7.3%, and radiology 8.2%. Several important findings are noted: (1) For a given disease there is marked variance of hospital charges. (2) Mean charges of emergency patients were 240% that of elective patients. (3) Consumption of services varies significantly within each group and between groups. This study demonstrates the importance of in depth financial analysis of therapies. This is a first step to identify the components of variance where reduction will not affect quality of care.     

Surgonomics: the cost dynamics of craniotomy

Prospective payment systems using the diagnostic related group (DRG) mechanism are being phased in for Medicare inpatient hospital care. The purpose of this study was to examine a common neurosurgical procedure (001), craniotomy without trauma, and characterize the cost dynamics of this DRG. All patients (n = 50) treated in this DRG at the Long Island Jewish Medical Center during 1983 had their financial charges exclusive of physician fees examined. The findings were: (a) each hospital service category had wide charge variances around the mean; (b) emergency (ER) admissions were 200% more expensive than nonemergency (non-ER) admissions; (c) ER admissions seemed to have no greater severity of illness than non-ER admissions, but had a significantly different referral pattern (i.e., admission from the ER to a nonneurosurgical service with a subsequent neurosurgical referral); (d) this DRG when grouped into clinical "subproducts" (i.e., craniotomy for tumor, hematoma, hydrocephalus, aneurysm, benign cyst, and other) showed marked charge differences; and (e) the most expensive 25% of patients had five times higher charges than the least expensive 25% for both ER and non-ER admissions. This type of financial analysis may give surgeons a methodology with which to address the problems of cost containment in a more serious manner.     

Does method of surgeon payment affect surgical care?

The method of surgeon payment influences several important aspects of surgical care. The preoperative processes of laboratory tests and radiographic procedures were performed more frequently and less selectively by salaried surgeons without any corresponding improvement in outcome. Socioeconomic factors and difference in severity of disease accounted for most of the variations in outcome, but in appendicitis there was a trend for fee-for-service surgeons to undertake earlier operation resulting in fewer secondary complications. Although the patient-physician relationship was least developed by salaried surgeons, this was not reflected in any less knowledge of the procedure by the patient or dissatisfaction with surgical care. Operative workloads were highest for surgeons receiving salary plus percentage in fee-for-service group practice.     

Surgonomics. Money down the drains

The importance of delivering cost-effective quality surgical care has increased with the introduction of new payment mechanisms designed to slow the rise in health care costs. We examined the reasons for the use of a commonly used surgical input--a drain--to determine surgeons' feelings about the importance of costs. Both resident and attending general surgeons felt that the cost of the input was not an important consideration in the decision-making process of choosing the input. We believe that these findings are applicable across the range of inputs (hospital days, laboratory tests, ancillary procedures) used by surgeons in their practices. Unless this changes in the future, surgeons will not be able to provide quality surgical care within economic constraints.     

Financial impact of in-house attending surgeon: a prospective study

Background

Current work hour restrictions have required some programs to have staff surgeons cover in-house call. Other programs have considered in-house staff coverage at night for the billable tasks performed during these hours. However, there have been no data published describing the load or value of work that an in-house team performs at night. Therefore, we prospectively recorded tasks performed in a pediatric surgery training center after staff had left for the night.

Methods

Between April 2005 and March 2006, all services rendered from 6:00 pm to 6:00 am that would require staff presence were prospectively recorded by a pediatric surgical fellow on-call. Tasks performed while staff was in the hospital were excluded. Time of service was recorded and assigned to an hour of the night. Billing codes were identified for each task, and relative value units were assigned. The collectable amount for services was calculated using 2006 Medicare reimbursement. Data were analyzed in functional blocks (6:00-10:00 pm, 10:00 pm-4:00 am, and 4:00-6:00 am).

Results

Data from 111 call nights were collected over the year. Attending staff was in-house 10 of those nights. Of the remaining 101 nights, peak hour of activity was from 12:00 am to 1:00 am (35 nights). In the 10:00 pm to 4:00 am time block, service was rendered 80 nights considering all activity, 68 nights if trauma/burns were excluded, and 45 nights excluding trauma/burns and nonoperative admissions. The sum collectable for all overnight services for the year was $25,855.

Conclusion

The in-house resident team performs tasks through the middle of the night on most nights. However, billable revenue generated by these tasks is very small compared with revenue generated from the normal operative schedule.     

Documentation of care and prospective payment. One hospital''s experience

Hospitals are now being reimbursed by Diagnosis Related Group (DRG) for Medicare patients. The Johns Hopkins Hospital has worked successfully under this system for the past 5 years, with cost increases being maintained well below the national average. Allowable revenue varies considerably by diagnosis depending on such factors as secondary diagnoses, procedure, and patient age. Failure to document accurately may result in substantial loss of hospital income. More worrisome is the use of data by outside agencies to evaluate quality of care. Recent reports of mortality rates for surgery in Maryland hospitals and of permanent pacemaker use are illustrative. Conclusions were inaccurate because of inadequate documentation of diagnoses and procedures by physicians and inaccurate coding by quality assurance coordinators. Surgeons need to be aware that in the prospective payment era, accurate and complete documentation is essential and that their data are likely to be used for purposes other than monitoring fiscal performance.     

Prospective payment systems and hip fracture treatment costs

We studied the health care consumption and costs after a hip fracture in 1,060 and 1,178 elderly patients admitted from their own home before and after the implementation of a prospective payment system in Stockholm. The total number of bed-days was estimated by merging the inpatient database and the municipal records of living accommodations for the elderly. By using a detailed patient-related accounting system and separating cost for surgery and “hotel” cost, we could compare costs in different types of rehabilitation. After the change in reimbursement system, the orthopedic stay was almost halved from 20 to 12 days. This was achieved by earlier and increased discharge to geriatric wards, where bed-day consumption doubled (107%), so that the total cost actually increased by 12%. This is not readily apparent from the official health care statistics, which depict a more favorable cost development, as diagnosis-related registration for a large part of the geriatric care is no longer included. In contrast, a rehabilitation program in one of the acute hospitals, emphasizing continuity in the postoperative phase, reduced the total cost for treatment and rehabilitation by 12%. A prospective reimbursement aiming at reducing the costs of acute care does not necessarily result in overall savings.     

Measurements of shoulder mobility by patient and surgeon correlate poorly: a prospective study

A questionnaire, which allowed graphing of self-assessment of active and passive shoulder motion by drawing lines onto prepared diagrams, was sent to 221 consecutive patients scheduled to attend our outpatient clinic. At consultation, shoulder motion was measured using a goniometer by surgeons, who were blinded to the results of the patient-based self-assessment. One-hundred and fifty-eight complete data sets were available for evaluation. Mean differences between patient and surgeon measurements were 18 degrees +/- 19 degrees . While mean values for most degrees of freedom were similar between patient and surgeon measurements, some rotational movements were overestimated by patients. Correlation of patient and surgeon based assessments were poor for all degrees of freedom (r(2) 相似文献   

Case-mix adjustment for an expanded renal prospective payment system

Medicare is considering an expansion of the bundle of dialysis-related services to be paid on a prospective basis. Exploratory models were developed to assess the potential limitations of case-mix adjustment for such an expansion. A broad set of patient characteristics explained 11.8% of the variation in Medicare allowable charges per dialysis session. Although adding recent hematocrit values or prior health care utilization to the model did increase explanatory power, it could also create adverse incentives. Projected gains or losses relative to prevailing fee-for-service payments, assuming no change in practice patterns, were significant for some individual providers. However, systematic gains or losses for different classes of providers were modest.     

Aquaporins and the surgeon: cautionary tales

Nephrogenic diabetes insipidus (NDI) presents an uncommon but formidable clinical challenge in the surgical patient. Two recent cases of NDI with differing aetiology are presented. These cases and a review of the literature illustrate well the diagnosis, fluid and electrolyte imbalances seen and the strategy of treatment required in the post-operative setting. The central role of the recently discovered aquaporin channels in this condition is briefly outlined. Nephrogenic diabetes insipidus has a diverse aetiology and many of the hazards of the condition are peculiar to the surgical setting. The importance of management in a high dependency environment is highlighted.     

Opioid-free spine surgery: a prospective study of 244 consecutive cases by a single surgeon

BACKGROUND CONTEXTThere have been no reported efforts to eliminate opioid use for elective spine surgery, despite its well-known drawbacks.PURPOSEWe sought to test the hypothesis that opioid-free elective spine surgery, including lumbar fusions, can be performed with satisfactory pain control.STUDY DESIGN/ SETTINGThis study analyzes prospectively collected data from a single surgeon's patients who were enrolled into an institutional spine registry.PATIENT SAMPLEWe enrolled every consecutive surgical patient of author RAB between January 1, 2018 and July 13, 2019.OUTCOME MEASURESThe postsurgical opioid use, pain scores, emergency room visits, and readmissions were tracked.METHODSWe developed a comprehensive program for opioid-free pain control after elective spine surgery. In the initial stage, opioids were given “PRN” only, while in the second stage, they were avoided altogether. Student's t tests were performed to compare pain scores, and regression analyses were performed to understand drivers of opioid use and pain.RESULTSTwo hundred forty-four patients were studied, a third of whom underwent lumbar fusions. In the initial stage, 47% of patients took no opioids from recovery room departure until 1-month follow-up. During the second stage, 88% of patients took no opioids during that period. Pain scores were satisfactory, and there was no association between postoperative opioid use and either procedural invasiveness or pain scores. However, preoperative opioid use was associated with a nearly fivefold increased risk of postoperative use. Ninety-three percent of lumbar fusion patients who were opioid-free before surgery did not take a single opioid in the postoperative period.CONCLUSIONOpioid-free elective spine surgery, including lumbar fusions, is feasible and effective. We suggest that opioid-free spine surgery be offered to patients who are opioid-naïve or who can be weaned off before the operation.