Developing an Episode Based Payment Model for Acute Pancreatitis Hospitalizations

Abstract

Introduction: The episode based payment model (EBP) is one approach being explored to incentivize pay for quality and performance. Acute pancreatitis hospitalizations (episodes) which involve multiple providers with marked variations in management is an ideal disease to explore this model of reimbursement. The aim of the study is to model the cost of care for acute pancreatitis hospitalizations using consensus guidelines (gold standard) to determine variations in cost of care. Methods: Patient encounters from a single health plan were retrospectively identified using a single ICD 9 code (577.0) for acute pancreatitis between 2011 and 2015 to derive an EBP model. Only acute care encounters were used in model building. To ensure the use of the best evidence available, we utilized the IAP/APA and ACG guidelines for the management of acute pancreatitis as a way to identify variations in care. Imaging utilization in the first 24 hours (abdominal computed tomography CT, abdominal ultrasonography), length of stay (LOS), location of care and cost (USD) were obtained. Results: There were 123 patients identified during the study period of which 65 patients (53%) received management in the acute care setting. The average age was 42 years old and the majority were female (54%). The mean LOS was 2 days and the average cost of an encounter was $6,131. Twenty- seven patients (42%) in the health plan sought care at neighboring, non-academic hospitals. Using multivariable linear regression, CT imaging ($1656, p = 0.018), prolonged LOS ($1765, p < 0.0001) and care outside of our institution ($1921, p = 0.007) were all shown to be significant linear predictors of higher cost (Figure 1). The overall EBP model was able to explain 60% of the variation in cost and was statistically significant (P < 0.0001). Conclusion: Practice guidelines are seldom used to determine how deviations affect cost. For acute pancreatitis, our preliminary EBP model suggests that LOS, CT imaging and care at an academic center (high volume) statistically impact inpatient costs. Clinical Implications- Incorporating clinical guidelines in episode based payment models may be a better way to inform clinicians how deviation from guidelines impact the overall cost of healthcare.Table 1: Optimized linear model of cost in all patients in the cohort