Variation in Hospital Costs and Reimbursement for Endovascular Aneurysm Repair—A Vascular Quality Initiative Pilot Project

Abstract

Comparing costs between centers is difficult because of the heterogeneity of vascular procedures contained in broad diagnosis-related group (DRG) billing categories. The purpose of this pilot project was to develop a mechanism to merge Vascular Quality Initiative (VQI) clinical data with hospital billing data to allow more accurate cost and reimbursement comparison for endovascular aneurysm repair (EVAR) procedures across centers. Sixteen VQI centers volunteered to submit UB04 billing data for 666 primary, elective infrarenal EVAR procedures performed by 93 surgeons in 2014. Procedures were categorized as standard or complex (with femoral-femoral bypass or additional arterial treatment) and without or with complications (estimated blood loss >300 mL, artery injury, myocardial infarction, congestive heart failure, respiratory, renal, reoperation), yielding four clinical groups for comparison. Charge data were analyzed by MedAssets, Inc to derive costs using cost-to-charge ratios for each cost category. Cost variation was analyzed across centers and compared with EVAR DRG 238 (without complications) and 237 (with complications) categorization. Of all cases, 63% were standard and 27% had complications, with wide variation between centers (Table). Mean total costs ranged from $31,100 for standard EVAR without complications to $47,400 for complex EVAR with complications and varied twofold to threefold among centers (Table). Implant costs for standard EVAR without complications varied from $8000 to $26,000 across centers. Average Medicare reimbursement was substantially less than total cost except for standard EVAR without complications (Table). Only 26% of procedures with complications in VQI were reported in the higher reimbursed DRG 237 category (center range, 0%-21%). Length of stay or operative time did not correlate with total cost. VQI data allow more precise EVAR cost comparison by identifying comparable clinical groups compared with DRG-based calculations. Total costs exceeded Medicare reimbursement, especially for patients with complications, although this varied by center. Implant costs also vary more than expected between centers for comparable cases. Incorporation of VQI elements demonstrating EVAR case complexity into billing data may allow centers to better align respective DRG reimbursement to total costs.TableEndovascular aneurysm repair (EVAR) cost comparisonEVAR 2014 (N = 666)Without complicationsWith complicationsStandardComplexStandardComplexPercentage of total51% (38%-70%)22% (13%-31%)12% (6%-23%)15% (6%-35%)Total cost$31.0K (21-49K)$35.1K (19-67K)$47.1K (32-71K)$47.4K (34-77K)Implants$17.5K (8.1-26K)$19.8K (9.4-35K)$19.7K (9.2-35K)$21.4K (9.2-36K)Medical/surgical supplies$3.5K (0.5-10K)$4.3K (0.6-13K)$5.3K (1.2-13K)$5.5K (1.0-14K)Operating room/anesthesia$4.9K (1.0-9.5K)$5.4K (1.3-11K)$7.4K (2.2-21K)$8.0K (1.9-15K)Room/board length of stay$2.4K (1.1-4.2K)$2.5K (0.6-9.1K)$7.7K (0.8-15K)$6.6K (1.9-14K)Ancillary$2.1K (0.5-4.6K)$2.4K (0.2-5.3K)$5.1 (0.2-11K)$4.6K (0.9-9.6K)Pharmacy$0.6K (0.1-1.4K)$0.7K (0-1.4K)$1.9 (0.1-5.1K)$1.3K (0.1-2.4K)Reimbursement$29.8K (21-47K)$28.6K (22-49K)$35.7K (22-50K)$34.8K (34-77K)Mean values (range from low to high across 16 centers).Cost data reflected per (K) = $1000. Open table in a new tab