Abstract
High use of subspecialty care is an important source of health care spending. Medical subspecialty care in particular may duplicate the scope of practice of the primary attending physicians for patients hospitalized for medical conditions. Under value-based payments, which aim to control overall spending during an episode of hospitalization (including Part B physician fees), subspecialty consultations may be a target for hospitals working to reduce costs. To measure the use of subspecialty consultation for Medicare beneficiaries hospitalized for nonsurgical conditions; to compare payments for consultative and nonconsultative care, adjusted for case mix and demographics; and to measure variation in payments across hospital referral regions (HRRs). This retrospective cross-sectional study included a 15% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A and B and identified all discharges after acute care hospital stays for nonsurgical conditions from January 1 through December 31, 2014. A total of 735 627 discharges were included. The analyses were conducted from December 1, 2017, through February 12, 2019. Total Part B payments were extrapolated to the population of Medicare fee-for-service beneficiaries. Probability of any consultation during a hospitalization was estimated using logistic regression. The number of consultations per stay and the number of consultative visits per hospital day were estimated using Poisson regression. Part B payments for consultative and nonconsultative care were estimated using generalized linear regression with gamma-log link. All models were adjusted for patient demographics and case mix. Payment models also included HRR fixed effects. A total of 735 627 discharges from 4534 hospitals in 2014 were included in the analysis (41.2% men and 58.8% women; mean [SD] age, 79.6 [8.9] years; 84.7% white, 10.1% black, and 5.2% other race). After adjusting for patient case mix and demographics, a 6-fold variation between the top and bottom quintiles of hospitals (relative difference, $401 [95% CI, $368-$434]) and HRRs (relative difference, $363 [95% CI, $337-$389]) was found in payments per stay for consultative care. Part B payments for consultative care by medical subspecialists accounted for 41.3% of payments for physician visits during hospitalization and totaled $1.3 billion in 2014. The substantial variation in the use of subspecialty consultative care suggests potential opportunities for cost savings.
Highlights
Value-based payment models are based on the premise that health care professionals can deliver better care at a lower cost.[1]
Under value-based payment models that focus on inpatient care, which aim to control overall spending during an episode of hospitalization, subspecialty consultations may be a target for hospitals working to reduce costs.[5]
For stays with a generalist attending, a median of 0.78 different specialties was consulted per hospital stay (IQR, 0.51-1.13), with a median of 0.40 consultative care visits per day (IQR, 0.26-0.57)
Summary
Value-based payment models are based on the premise that health care professionals can deliver better care at a lower cost.[1]. Primary care or generalist physicians have increasingly delegated more care to subspecialist physicians.[6,7,8,9,10,11] In the ambulatory setting, the number of referrals from primary care physicians to subspecialists grew 94% between 1999 and 2009.10 Whether this increase reflects a necessary specialization of clinical practice in response to patient complexity or duplicative care in response to nonclinical pressures such as malpractice or productivity is not clear.[12]
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