Cost-containment Strategies Research Articles

Surgeons' Perspectives on Premium Implants in Total Joint Arthroplasty.

Declining total joint arthroplasty reimbursement and rising implant prices have led many hospitals to restrict access to newer, more expensive total joint arthroplasty implants. The authors sought to understand arthroplasty surgeons' perspectives on implants regarding innovation, product launch, costs, and cost-containment strategies including surgeon gain-sharing and patient cost-sharing. Members of the International Congress for Joint Reconstruction were surveyed regarding attitudes about implant technology and costs. Descriptive and univariate analyses were performed. A total of 126 surgeons responded from all 5 regions of the United States. Although 76.9% believed new products advance technology in orthopedics, most (66.7%) supported informing patients that new implants lack long-term clinical data and restricting new implants to a small number of investigators prior to widespread market launch. The survey revealed that 66.7% would forgo gain-sharing incentives in exchange for more freedom to choose implants. Further, 76.9% believed that patients should be allowed to pay incremental costs for "premium" implants. Surgeons who believed that premium products advance orthopedic technology were more willing to forgo gain-sharing (P=.040). Surgeons with higher surgical volume (P=.007), those who believed implant companies should be allowed to charge more for new technology (P<.001), and those who supported discussing costs with patients (P=.004) were more supportive of patient cost-sharing. Most arthroplasty surgeons believe technological innovation advances the field but support discussing the "unproven" nature of new implants with patients. Many surgeons support alternative payment models permitting surgeons and patients to retain implant selection autonomy. Most respondents prioritized patient beneficence and surgeon autonomy above personal financial gain. [Orthopedics. 2017; 40(5):e825-e830.].

The Role of Physicians in Rationing Cancer Care. Attitudes of German Oncologists

Background: Against the background of limited resources, the rise in the cost of therapy as well as in the number of cancer patients fuels the discussion about the necessity to ration, i.e., setting limits to beneficial treatment for cost reasons. Recently, we presented the self-reported prevalence of bedside rationing among German oncologists. Here, we describe oncologists' views on cost containment strategies and their role therein. Methods: We performed an online survey including structured questions and free field sections with the members of the German Society of Hematology and Oncology. Results: In the perception of oncologists, cost considerations and negotiations are gaining in importance and consume considerable working time. This negatively affects job satisfaction in 72% of the 345 respondents. Oncologists are concerned that the quality of care will suffer from rationalization and implicit rationing. They are ambivalent as to who is best suited to decide about resource rationing: 66% support the view that limits for costly procedures should be set by a form of commission; nevertheless, 48% consider physicians as the best decision makers in these situations. Conclusion: We suggest a broad public discussion and an interdisciplinary debate among the oncology community to define and legitimize decisions on rationing by setting explicit criteria.

Assessment of the potential impact of dose rounding parenteral chemotherapy agents on cost savings and drug waste minimization.

Background Fiscally responsible utilization of anticancer treatments is necessary to combat their continually increasing cost. Dose rounding is one strategy that has been explored to minimize cost and waste without losing clinical effectiveness. Objectives To determine if dose rounding chemotherapy agents is a feasible cost-containment strategy at an institution with a small oncology clinic. Methods This study is a retrospective chart review of all body surface area dosed parenteral chemotherapy prescribed for an oncological diagnosis over a 12-month period (1 October 2015-30 September 2016). Chemotherapy doses were rounded down by 5%. Doses for patients with metastatic diagnoses were also rounded down by 10%. Rounded doses were evaluated for a potential decrease in vial size. Cost was represented as dollar/milligram of drug. Potential for drug waste minimization was also calculated. Results There were 877 total doses of chemotherapy administered to 70 unique patients throughout the 12-month duration of the study. When doses were rounded down by 5%, 140 doses qualified for a decrease in vial number. The potential for cost savings was $22,849 with 83,802 mg saved from wastage. A 10% decrease resulted in the reduction of vials for 248 doses, a potential savings of $30,911 with 129,011 milligrams saved. The targeted agents accounted for the majority of savings, $16,920 of the $22,849 with 5% rounding and $20,086 of the $30,911 with 10% rounding. Conclusion Dose rounding has the potential to be an effective cost-containment strategy in low volume oncology clinics.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-componentdifferences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. Level II, economic analysis.

Intravenous vs. oral hydration administration for optimal ureteral opacification in computer tomographic urography.

Computed tomographic urography (CTU) is the gold standard in the radiologic detection of urinary tract disease. The goals of CTU protocols are to garner fully distended and opacified collecting systems, ureters, and bladder for adequate evaluation. Multiple techniques have been reported in the literature to optimize urinary tract visualization and enhance genitourinary assessment. However, currently no strict guidelines exist regarding the preferred method for optimal urinary tract opacification in CTU. During the year 2013, a retrospective chart review of CTU examinations were done at either an academic institution where IV hydration was routinely administered or at an outpatient imaging center where oral hydration was preferred. Two attending radiologists experienced in cross-sectional body imaging, retrospectively reviewed all the images, blinded to the method of hydration. The reviewers were asked to quantify ureteral distension as well as to grade urinary tract opacification. A total of 176 patients and 344 ureters were analyzed. Mean maximal ureteral widths were largest in the mid ureter, followed closely by the proximal ureter. Mean opacification scores showed no statistical significance between hydration methods, stratified by ureteral segment. Our study results show that oral hydration is easy to implement, produces ureteral distention and opacification similar to CTU studies with IV hydration, without loss of diagnostic quality in our select patient population. Although not statistically significant, the oral hydration protocol is more cost effective, requires less hospital resources, and may be a useful step toward cost-containment strategies pertinent in today's healthcare landscape.

Cost of nursing most frequent procedures performed on severely burned patients.

to identify the mean direct cost (MDC) of the most frequent procedures performed by nursing professionals on severely burned patients in an Intensive Care Unit. exploratory-descriptive quantitative single-case study. The MDC was calculated by multiplying time (timed) spent by nursing professionals in the performance of the procedures by the unit cost of direct labor, and adding the costs of material and medicine/solutions. a MDC of US$ 0.65 (SD=0.36) was obtained for "vital signs monitoring"; US$ 10.00 (SD=24.23) for "intravenous drug administration"; US$ 5.90 (SD=2.75) for "measurement of diuresis"; US$ 0.93 (SD=0.42) for "capillary blood glucose monitoring"; and US$ 99.75 (SD=129.55) for "bandaging". the knowledge developed can support managerial decision-making, contribute to the efficiency distribution of the resources involved and, when possible, provide cost-containment or cost-minimization strategies without impairing the quality of nursing care.

Health Care Costs Associated with Addition, Titration, and Switching Antihypertensive Medications After First-Line Treatment: Results from a Commercially Insured Sample.

Treatment modifications are necessary for addressing issues related to efficacy and tolerance of first-line monotherapy, but they increase the economic burden on patients and their health plans. Understanding the differences in costs between alternative treatment modification strategies, if any, can serve as a guideline for clinical decision making and for designing cost-containment strategies. To compare the health care utilization costs between (a) addition (i.e., use of free-pill combinations [FPCs] or fixed-dose combinations [FDCs]) and uptitration as alternatives for addressing efficacy issues and (b) switching and downtitration as alternatives for addressing tolerance issues with first-line antihypertensive monotherapy. This is a retrospective cohort study that used the 2008-2012 BlueCross BlueShield of Texas claims database. Patients who had a treatment modification within 12 months of initiating antihypertensive monotherapy were identified. All-cause and disease-related health care utilization costs and drug costs were estimated from the BlueCross BlueShield health plan's perspective over a 12-month period, starting from the date of treatment modification. Propensity score-adjusted generalized linear models were used to compare costs between alternative treatment modification strategies. We identified 5,998 patients who met study criteria and had a modification of treatment: FPC (n = 1,395), FDC (n = 1,207), uptitration (n = 1,659), switching (n = 1,282), and downtitration (n = 455). All-cause and disease-related health services utilization costs were estimated for 12 months following treatment modification. Mean annual drug utilization costs were highest for the FDC strategy. All-cause inpatient and outpatient services utilization costs were significantly different between strategies used for addressing issues of tolerance and efficacy, respectively. Disease-related inpatient services utilization costs were lower for the FDC strategy compared with the uptitration strategy. However, disease-related inpatient services utilization costs were not significantly different for the downtitration strategy compared with the switch strategy. Health care costs following treatment modifications vary by type of strategy. The high costs of FDCs may be offset by the reduction of inpatient services utilization costs. Careful consideration should be given to the differences in costs between alternative strategies. No outside funding supported this study. The dataset used in this study was created for dissertational research on the patterns and outcomes of treatment modification in hypertensive patients. Data and database support were provided by University of Texas School of Public Health/BlueCross BlueShield of Texas research program in payment systems and policy. Sonawane Deshmukh was an employee of Anthem BlueCross BlueShield from August 2015 to August 2016. Hansen has received consulting funds from Daichii Sankyo and has provided expert testimony for Allergan and Boehringer Ingelheim. All other authors have no known conflicts of interest. Study concept and design were contributed by Sonawane Deshmukh, Garza, Wright, and Hansen. Sonawane Deshmukh and Ganduglia Cazaban collected the data, and data interpretation was performed by Sonawane Deshmukh, Qian, Wright, and Zeng. The manuscript was written primarily by Sonawane Deshmukh, along with Qian and Garza, and revised by Sonawane Deshmukh, Qian, Ganduglia Cazaban, and Hansen.

Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees

Several policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy. To determine the association of home health copayments with use of home health services. A difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans. Introduction of copayments for home health care between 2007 and 2011. Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care. Copayments for home health visits ranged from $5 to $20 per visit, which were estimated to be associated with $165 (interquartile range [IQR], $45-$180) to $660 (IQR, $180-$720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, -0.15 percentage points; 95% CI, -0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, -0.01 to 0.03), and home health days per user (adjusted difference-in-differences, -0.19; 95% CI, -3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care. We found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.

Will Virtual Pediatric Subspecialist Networks "Disrupt" Existing Narrow Networks?

Health plans try to maintain profit margins and limit rising premiums as escalating drug prices, expensive new technologies, and higher physician and hospital expenditures increase health care costs. Rural areas have the additional issue of adverse risk because young, healthier people often move to live in urban areas, leaving an older, sicker population in these communities. Health plan cost-containment strategies include having a narrow network that excludes primary care, specialty, and pediatric subspecialty physicians whose practice patterns and/or high payment rates result in higher costs. When a health plan’s physician network is restricted (narrow), the plan has more leverage to negotiate favorable payments because a high proportion of the patients in a participating physician’s practice are enrolled in the plan. Having a network that has fewer specialists and pediatric subspecialists may also discourage the enrollment of children and adults with chronic and complex conditions when they recognize that their physician does not participate in the plan. When a plan has fewer sick enrollees, it can have lower premium costs, which also encourages enrollment of lower … Address correspondence to Stephen Berman, MD, FAAP, 13199 E Montview Blvd, Suite 310, A090, Aurora, CO 80045. E-mail: stephen.berman{at}childrenscolorado.org

The Development of Intra-Departmental Stratification and Competition for Resources: A Case Study of a Non-Research Based Higher Education Institution

Fluctuations in the financial welfare of institutions of higher education have long been tied to our country’s economic well-being. For many institutions the most recent financial downturns have led to historic revenue and enrollment difficulties that have necessitated the use of cost containment strategies to conserve dwindling resources. Included in these tactics are resource allotment decisions that reflect administrative favor towards some academic departments, leading to the development of a prestige-based stratification system and competition driven funding. A case study of a non-research based institution is used to take a preliminary look at the impact of institutional resource conservation on intra-departmental competition for resources and disparate funding allocations across disciplines in this setting. Special attention is given to the trends in enrollment and the selection of particular academic majors that have occurred across time and in response to the institution’s continued fiscal difficulties.

CASE STUDY ON AN IPILIMUMAB COST-CONTAINMENT STRATEGY IN AN ITALIAN HOSPITAL.

Ipilimumab is the first licensed immune checkpoint inhibitor for treatment of melanoma. The promising results of the registration clinical study need confirmation in real practice and its clinical success comes together with a relevant budget impact due to the high price of this drug. The aim of this work is to describe a new model of economical sustainability of ipilimumab developed in an Italian reference center for melanoma treatment. This retrospective, observational, and monocentric study was carried out at the Veneto Institute of Oncology. Ipilimumab was administered to fifty-seven patients with advanced melanoma. Overall survival, progression free survival, and toxicity were evaluated. A local management procedure was evaluated together with the cost-saving strategies implemented by the Italian Medicines Agency (AIFA). We demonstrated that the use of ipilimumab for metastatic melanoma in real practice had an efficacy and toxicity similar to that reported in the literature. In this scenario, our management model (centralization of compounding + drug-day) permitted savings up to the 11.1 percent of the gross cost for the drug (calculated assuming that no cost saving procedures were applied) while the policy of cost containment designed by AIFA produced an additional 6.2 percent of savings. In real practice conditions, the centralized administration of ipilimumab allows to replicate the results of clinical studies and in the meantime to contain the cost associated with this drug. The local strategy of management can be readily applied to most of the high cost drugs compounded in the hospital pharmacy. Impact of findings on practice: (i) We describe a new model of economic sustainability (drug-day, centralization of compounding, payback systems) of an expensive and innovative drug, ipilimumab, for treatment of melanoma within an Italian cancer center. (ii) This pivotal study demonstrated that a cost containment strategy is feasible and it needs the cooperation of all healthcare providers (oncologists, pharmacists, nurses, and technicians) to guarantee the full efficiency of the process.

The Ethics of Patient Cost-Sharing for Total Joint Arthroplasty Implants.

The number of total joint arthroplasties being performed in the United States continues to grow1-3. Current estimates are that approximately 512,000 hip arthroplasties and 787,000 knee arthroplasties are performed yearly4. Many of these procedures are performed on Medicare recipients (approximately 400,000), and total joint arthroplasty represents the largest share of Medicare spending among inpatient surgical procedures5-7. The Centers for Medicare & Medicaid Services (CMS) has developed alternative payment models designed to decrease costs without negatively affecting outcomes. The Bundled Payment for Care Improvement program and the Comprehensive Care for Joint Replacement (CJR) program are recent attempts to control total joint arthroplasty cost8. It is unclear what effect these programs will have on outcomes, quality, or patient access. The cost of implants is highly variable and represents a substantial financial portion of a total joint arthroplasty episode of care9. Therefore, among other factors, cost containment strategies must focus on lowering implant costs. Moreover, many higher-cost prostheses have unproven clinical benefits. This has led to novel discussions among surgeons and hospitals about whether patients should contribute to the costs of their implants. There are examples of patients paying for medical devices; however, there is no mechanism in place for patients to contribute toward arthroplasty implants10. Previous research suggests that U.S. patients are willing to pay for implants, and their motivations for doing so may be varied11-14. Allowing patients to cost-share for implants generates myriad ethical dilemmas, and this article will review those dilemmas. This article will not discuss patient cost-sharing in other areas. Patient cost-sharing for implants has real potential to enhance patient autonomy, to increase transparency, to respect shared decision-making, and to strengthen the health-care system’s long-term financial viability. However, the …

Operational and Clinical Strategies to Address Drug Cost Containment in the Acute Care Setting.

To provide clinical and operational strategies to generate drug cost savings in the hospital setting. A search of the PubMed database was performed with no time limit through July 2016. All original prospective and retrospective studies, peer-reviewed guidelines, consensus statements, review articles, and accompanying references were evaluated for inclusion. Only articles published in the English language were included. Investigators reviewed 937 abstracts. The review of the literature showed that acute care hospitals are under increasing financial pressures, and the pharmacy is often responsible for opportunities to manage drug costs. The literature also indicated that cost-containment strategies in the acute care setting range from pharmacy-directed activities to initiatives requiring interdisciplinary collaboration and strategic planning. Hospital pharmacies should consider establishing an interdisciplinary team that is responsible for systematically reviewing drug cost implications and leading any initiatives that are deemed necessary. Acute care settings can use various operational and clinical strategies to lower their expenditures on high-cost drugs. Operational strategies include various activities that pharmacy staff implement related to contracting, purchasing, and inventory management. Clinical strategies utilize clinical pharmacists working with interdisciplinary teams to develop and maintain a formulary, implement established-use criteria for select drugs, use dose optimization, and implement other clinical tactics aimed at cost containment. After initiatives are implemented, assessing the outcomes of the initiatives is important to determine how successful they were at lowering costs safely and effectively. Acute care hospitals can use various operational and clinical strategies to lower overall drug costs. A systematic stepwise approach is recommended to ensure relevant drugs are regularly reviewed and addressed as needed.

The Promotion of Cross-Border Medical Tourism in Developing Countries: Economic Growth at the Expense of Healthcare System Efficiency and Cost Containment?

Background:More and more developing nations are promoting cross-border medical tourism as a way to enhance economic growth. Major destinations for medical tourism in South and Southeast Asia include India, Thailand, Malaysia and wealthy Singapore. Much has been written on the pros and cons of the growth of medical tourism for both destination and source countries. This article uses a different approach.Methodology:Examples from India, Thailand and Malaysia are used to discuss the actual and potential impact of medical tourism on healthcare system efficiency and costs.Results and Conclusions:Based on the experience of these three countries, it is argued that the promotion of cross-border medical tourism to enhance economic growth is likely to be at the expense of national healthcare system efficiency as it goes directly against cost containment strategies and measures.

Controlling Health Care Spending: More Patient "Skin in the Game?"

While health care cost inflation slowed during the past few years, it has started to pick up again, and policy makers have good cause for concern about future increases in health care spending. Moreover, even if future increases moderate, policy makers rightly worry about the already high levels of U.S. spending. The need for effective cost containment strategies in health care persists, even though the Affordable Care Act appears to have had some success at containing health care costs.Health care spending reforms can focus on physician and hospital practices or on patient behavior, and popular reform proposals include both approaches. For example, rather than paying physicians and hospitals in terms of the quantity of care that they provide and encouraging the provision of too much care, private insurers and government programs are turning more and more to forms of reimbursement that are based on the quality of care delivered. Insurers often adjust physicians’ compensation based on whether they screen their patients for cancer or high cholesterol, administer recommended immunizations, or achieve good control of blood sugar levels for their patients with diabetes. The Affordable Care Act addresses patient behavior by requiring insurers to cover important kinds of preventive care for free. That way, people will not be discouraged for financial reasons from seeking early care that can keep them healthier and avoid the need for hospitalizations and other expensive treatments.In this article, I consider an increasingly common strategy that insurers use to influence patient behavior — giving people more “skin in the game.” When medical treatment can be obtained at very low cost, people may be too quick to seek it when they feel sick, visiting their physicians when they would do just as well by staying home. Hence, insurers have raised deductibles and co-payments and shifted the costs of care to patients in other ways in the hope that people will become more conscious of the costs of their care. Although concerns about patients seeking too much care are important, common strategies for giving patients more skin in the game have been poorly conceived. There is room for skin-in-the-game strategies to contain high health care spending, but only when they are properly designed.

Variations in hospitals costs for surgical procedures: inefficient care or sick patients?

BackgroundReducing unwanted variations has been identified as an avenue for cost containment. We sought to characterize variations in hospital costs after major surgery and quantitate the variability attributable to the patient, procedure, and provider. MethodsA total of 22,559 patients undergoing major surgical procedure at a tertiary-care center between 2009 and 2013 were identified. Hierarchical linear regression analysis was performed to calculate risk-adjusted fixed, variable and total costs. ResultsThe median cost of surgery was $23,845 (interquartile ranges, 13,353 to 43,083). Factors associated with increased costs included insurance status (Medicare vs private; coefficient: 14,934; 95% CI = 12,445.7 to 17,422.5, P < .001), preoperative comorbidity (Charlson Comorbidity Index = 1; coefficient: 10,793; 95% CI = 8,412.7 to 13,174.2; Charlson Comorbidity Index ≥2; coefficient: 24,468; 95% CI = 22,552.7 to 26,383.6; both P < .001) and the development of a postoperative complication (coefficient: 58,624.1; 95% CI = 56,683.6 to 60,564.7; P < .001). Eighty-six percent of total variability was explained by patient-related factors, whereas 8% of the total variation was attributed to surgeon practices and 6% due to factors at the level of surgical specialty. ConclusionsAlthough inpatient costs varied markedly between procedures and providers, the majority of variation in costs was due to patient-level factors and should be targeted by future cost containment strategies.

Sarcopenia predicts costs among patients undergoing major abdominal operations

Although sarcopenia has been identified as a predictor of poor, postoperative, clinical outcomes, the financial impact of sarcopenia remains undetermined. We sought to evaluate the relationship between sarcopenia and hospital finances among a cohort of patients undergoing a hepato-pancreatico-biliary or colorectal resection. Clinical, financial, and morphometric data were collected for 1,169 patients undergoing operative resection between January 2011 and December 2013 at the Johns Hopkins Hospital. Multivariable regression analysis was performed to assess the relationship between sarcopenia and total hospital costs. Using sex-specific cutoffs for total psoas volume, 293 patients were categorized as sarcopenic. The presence of sarcopenia was associated with a $14,322 increase in the total hospital cost (median covariate-adjusted cost, sarcopenia versus no sarcopenia: $38,804 vs $24,482, P<.001). Patients who presented with sarcopenia demonstrated a higher total hospital cost within the subgroup of patients who developed a postoperative complication (sarcopenia versus no sarcopenia: $65,856 vs $59,609) and among those patients who did not develop a postoperative complication (sarcopenia versus no sarcopenia: $26,282 vs $23,763, both P<.001). Similarly, total hospital costs were higher among patients presenting with sarcopenia regardless of the length of stay for index admission (observed:expected, length of stay<1: sarcopenia versus no sarcopenia: $25,038 vs $22,827; observed:expected, length of stay>1: sarcopenia versus no sarcopenia: $43,283 vs $38,679, both P<.001). As measured by sarcopenia, patient frailty is inversely related to total hospital costs. Sarcopenia represents a novel tool for forecasting patient outcomes and operative costs and can be used to inform quality improvement and cost containment strategies.

Societal responsibility and moral hazard: How much are we willing to pay for quality-adjusted life?

Health care spending in the United States continues to rise with cancer care consuming a disproportionate amount of that spending. As the US population ages and cancer treatment options become more complex, cost containment strategies have become essential in oncology. Patient-centered decision-making will help to contain costs but requires a well-informed patient who is able to reconcile potential treatment choices with their beliefs and values. J. Surg. Oncol. 2016;114:269-274. © 2016 Wiley Periodicals, Inc.

Unpacking Payment Bundles.

Health care consists of 2 predominant drivers: the science behind the services provided to restore, maintain, or improve health; and the economics of paying the rehabilitation professionals and facilities that deliver these essential services. The confluence of science and economics has made the health care delivery system in the United States a complex one, with varied stakeholders and interests. To best manage this system, policy makers deploy strategies and tactics with an aim to get the best health outcome for the dollar spent.1 With many factors impacting the delivery of health care and how health care services are paid, policy makers are in a constant search to align best practice with the right economic incentives. Policy makers use legislation, regulation, and other policies to try to achieve alignment through efforts aimed at managing the benefit via (1) controls on patient access, (2) risk mitigation through cost-containment strategies for the payer, or (3) penalties and incentives to drive the rehabilitation professional's behavior and practice. The growth in health care spending in the past couple of decades has led to a growing need to reorganize the system to reduce cost, increase access, improve care coordination, and improve quality—and ultimately has led to reforms to shift costs to patients, manage payment through cost containment, or redesign care delivery. Bundling is a policy strategy that combines cost containment with delivery system reforms centered on care coordination and patient outcomes. Bundled payments are the consolidation of payment for a continuum of health care services for a defined population with a specified diagnosis or clinical condition for a specific episode of care.2 Bundled payment methodologies aim to strike a balance between fee-for-service and capitated payment models. They also seek to reduce the incentives of fee-for-service models when fragmented care has the potential to drive …

Do Health Reforms Impact Cost Consciousness of Health Care Professionals? Results from a Nation-Wide Survey in the Balkans.

Serbia, as the largest market of the Western Balkans, has entered socioeconomic transition with substantial delay compared to most of Eastern Europe. Its health system reform efforts were bold during the past 15 years, but their results were inconsistent in various areas. The two waves of global recession that hit Balkan economies ultimately reflected to the financial situation of healthcare. Serious difficulties in providing accessible medical care to the citizens became a reality. A large part of the unbearable expenses actually belongs to the overt prescription of pharmaceuticals and various laboratory and imaging diagnostic procedures requested by physicians. Therefore, a broad national survey was conducted at all levels of the healthcare system hierarchy to distinguish the ability of cost containment strategies to reshape clinician's mindsets and decision-making in practice. Assessment of healthcare professionals' judgment on economic consequences of prescribed medical interventions and evaluation of responsiveness of healthcare professionals to policy measures targeted at increasing cost-consciousness. Cross-sectional study. A nationwide cross-sectional survey was conducted through a hierarchy of medical facilities across diverse geographical regions before and after policy action, from January 2010 to April 2013. In the middle of the observed period, the National Health Insurance Fund (RFZO) adopted severe cost-containment measures. Independently, pharmacoeconomic guidelines targeted at prescribers were disseminated. Administration in large hospitals and community pharmacies was forced to restrict access to high budget-impact medical care. Economic Awareness of Healthcare Professionals Questionnaire-29 (EAHPQ-29), developed in Serbian language, was used in face-to-face interviews. The questionnaire documented clinician's attitudes on: Clinical-Decision-Making-between-Alternative-Interventions (CDMAI), Quality-of-Health-Care (QHC), and Cost-Containment-Policy (CCP). The authors randomly and anonymously recruited 2000 healthcare experts, with a total of 1487 responding; after eliminating incomplete surveys, 649 participants were considered before and 651 after policy intervention. Dentists (1.195±0.560) had a higher mean CDMAI score compared to physicians (1.017±0.453). The surgical group compared to the internist group had a higher total EAHPQ-29 score, CCP score and CDMAI score. Policy intervention had a statistically significant negative impact on the QHC score (F=4.958; df=1; p=0.027). There was no substantial impact of policy interventions on professional behavior and judgment with regard to the CDMAI, CCP, and total EAHPQ-29 scores. Although cost savings were forcibly imposed in practice, the effects on clinical decision-making were modest. Clinicians' perceptions of quality of medical care were explained in a less effective manner due to the severely constrained resources allocated to the providers. This pioneering effort in the Balkans exposes the inefficiency of current policies to expand clinicians' cost consciousness.