D. C. Sutzko1, A. Gonzalez2, A. Chakrabarti3, N. Osborne1 1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Illinois, Chicago,Surgery,Chicago, IL, USA 3University Of Michigan,Medicine,Ann Arbor, MI, USA
Introduction: There is growing interest in providing high quality and low cost care to Americans. Government and private insurers are pursuing avenues to measure not only how well hospitals are performing surgeries, but also at what cost. We sought to examine the variation in Medicare costs associated with a relatively homogenous and commonly performed vascular procedure, carotid endarterectomy (CEA), particularly focusing on total payments, including hospital payments, outlier payments, readmission payments and post-discharge care.
Methods: All patients undergoing CEA between 2009 and 2012 were identified in the MedPar database. Risk and Reliability adjusted mortality rates were generated for all hospitals. Hospital payment data was aggregated into DRG payments, outlier payments, physician services, readmission payments and post-discharge payments. Hospital quintiles of cost were then generated and variation in the component costs was examined. Hospital variables were examined using the American Hospital Association Annual Survey Data.
Results:A total of 277,167 patients underwent CEA between 2009 and 2012, in a total of 1631 hospitals. Median total Medicare payments for CEA were $10,620 (IQR $8,153, $13,678). Table 1 shows the proportion of payments attributable to DRG, outlier, readmission, physician and post-discharge payments. There was wide variation in the distribution of payments, however, minimal variation was observed in outlier payments or payments for readmission. Payments for the DRG itself, nursing care (ICU care) and other physician services (such as consultations) appear to be significant drivers of variation in total hospital payments. Interestingly, low volume hospitals have higher cost (p<0.001), and increased hospital risk and reliability-adjust mortality (p<0.001). High cost hospitals were more likely to be larger hospitals with more ICU beds and training programs.
Conclusion: Medicare payments for carotid endarterectomy vary significantly across the country. This variation can be broken down into costs incurred at the hospital (DRG, outlier, physician services and readmissions) and outside the hospital (post-discharge care). Variation in payments appears to be due to not only higher DRG related payments, but also nursing care and physician consultations. Future work is necessary to understand the intersection of cost and quality.
