Costs For Episodes Of Care Research Articles

Exploratory analysis of the cost of episodes of care in metastatic renal cell carcinoma in the United States.

55 Background: Treatment decisions in oncology care have financial implications. A shift in reimbursement from traditional fee-for-service models toward episode-based care sets the framework for assessing the value of therapies. The objective of this study was to determine episode-based total cost (medical and pharmacy) and resource utilization by therapy for patients with metastatic renal cell carcinoma (mRCC) using the Oncology Care Model methodology. Methods: Retrospective analysis of commercial claims data incurred between Jan 1, 2013 and Jun 30, 2018. Patients included had ≥1 claim with a diagnosis code of renal cell carcinoma (RCC), ≥2 claims for metastasis on or after initial RCC diagnosis date, evidence of any mRCC systemic therapy on or after initial mRCC diagnosis date, and continuous enrollment from ≥6 months before until ≥6 months after the index date and were ≥18 years old on the index date. Patients were classified by 1 of 6 therapy classes: tyrosine kinase inhibitors (TKIs) monotherapy, mechanistic target of rapamycin (mTOR) monotherapy, immuno-oncology (IO) monotherapy, other (e.g., interferon) monotherapy, changed therapy class (e.g., from TKI to mTOR), or traditional chemotherapy. Results: 606 commercially insured patients with mRCC met the inclusion criteria. Most received monotherapy, and 53% had ≥2 episodes. Specifically, 59% of TKI, 17% of mTOR, 28% of IO, 59% of other, 85% of changed therapy class, and 38% of chemotherapy patients had ≥2 episodes. IO patients had the longest average inpatient length of stay per episode (7 days; p = 0.0002). There were differences in total episode costs among each selected therapeutic class: TKI (n = 161; $61,417), mTOR (n = 30; $67,637), IO (n = 75; $92,082), other (n = 34; $98,877), changed therapy (n = 130; $84,480), and chemotherapy (n = 34; $55,743) (p < 0.0001). Conclusions: Differences in total episode costs exist in each monotherapy class used to treat mRCC, even in an episode-based structure. As healthcare financing shifts to alternative payment models, it is important to investigate overall episode cost of care for various therapies, as the cost for the individual drug may not accurately reflect the total episode value.

27. Costs and utility of postdischarge acute inpatient rehabilitation following adult spinal deformity surgery

BACKGROUND CONTEXT As the United States' health care system transitions to a value-based approach, defining costs for entire episodes of care is fundamental to determining value. This is particularly important for adults with spinal deformity (ASD) who undergo surgical intervention. PURPOSE To further the discussion on costs of operative care for ASD, this study aims to evaluate the costs and functional utility of postdischarge acute inpatient rehabilitation after surgery for ASD. STUDY DESIGN/SETTING Single-center, retrospective cohort analysis. PATIENT SAMPLE Adults with spinal deformity (ASD) who underwent operative intervention (>7 levels fused) at a single tertiary care referral center and who were discharged postoperatively to one acute inpatient rehabilitation facility. OUTCOME MEASURES Patient demographics, operative details, direct costs and length of stay for inpatient hospitilization and acute postoperative rehabilitation, and patient function, as assessed by the Functional Independence Measure (FIM) instrument. METHODS Patient demographics, operative details, and costs were obtained for the index operation's inpatient encounter. Data for acute rehabilitation included: direct costs, length of stay, and patient function, as assessed by the Functional Independence Measure (FIM) instrument [scores 18-30 (total assistance), 31-45 (maximal assistance), 46-63 (moderate assistance), 64-80 (minimal assistance), 81-100 (supervision), 101-125 (modified independence), 126 (complete independence)]. Student T-tests and Chi-square tests were used to compared continuous and categorical variables. Pearson's tests were used to assess correlations. p RESULTS Ninety patients (95 episodes of care; average age 70.5±10.6 years; male-31, female-59) were included. After operations, average inpatient length of stay was 8.2±2.6 days (4-16 days). Operative details included: posterior levels fused 13.6±3.6 (7-21 levels), posterior column osteotomies (per patient) 7±3.7 (range, 1-15; n=49 patients), forty-two 3COs (PSO-35, VCR-7), and 11 interbody fusions. Average direct costs were $90,738±$24,166 ($36,521–$141,090) for index inpatient stays and $38,808±$14,752 ($8,679–$100,829) for post-discharge acute rehabilitation (Figure 1). Patients spent an average of 11.7±4.0 days (2-28 days) in acute rehabilitation postdischarge. Average direct cost per day in rehabilitation was $3,338 ±$2,131 ($506-$4,340). Significant improvements in function (FIM) were observed [admit: 66±14 (15–91) vs discharge: 94±14 (54–116); % improvement: 29±14]. CONCLUSIONS Postdischarge inpatient acute rehabilitation following operations for adult spinal deformity is associated with an average direct cost of $38,808 per case. While rehabilitation resulted in significant functional improvements, it came at a very significant economic expense amounting to $3.7 million, which accounted for 30% of the costs for 95 episodes of care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Hospital ownership of postacute care providers and the cost of care.

Hospitals are facing incentives to manage the total cost of care for episodes of illness, including the costs of inpatient care as well as the cost of care provided by physicians and postacute care (PAC) providers. PAC is an especially important component of the overall cost of care. One strategy hospitals employ in managing this cost is to own PAC providers. Prior work on the relationship between PAC ownership and cost has reached mixed conclusions. The aim of this study was to examine the associations between the episodic costs of care and hospital ownership of PAC providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRF). We examine panel data on hospital ownership of PAC providers from the American Hospital Association for 2013-2015 and cost of care data from Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. Using ordinary least squares, we quantify the association between a hospital's PAC ownership choice (both ownership of any PAC provider and ownership of particular types of providers) and the episodic cost of care. In 2015, 80% of hospitals owned some type of PAC provider. We find that ownership of SNFs and HHAs is associated with a lower episodic cost of care, whereas ownership of inpatient rehabilitation facilities is associated with higher episodic costs of care. The effects of ownership do not differ for hospitals that participate in a voluntary shared saving program (Bundled Payment for Care Improvement). The effects of PAC ownership vary by the type of PAC provider owned. Our results suggest that ownership of SNFs and HHAs may be a viable strategy for success in reimbursement programs that reward hospitals for managing the total costs for episodes of care.

High-Value Home Health Care for Patients With Heart Failure: An Opportunity to Optimize Transitions From Hospital to Home.

In recent years, public reporting, targeted financial penalties, and incentives to develop alternative payment models that include the assumption of financial risk have compelled hospitals to focus on reducing readmission rates for high-cost conditions such as heart failure (HF). When older patients with multiple medical conditions including HF are discharged from the hospital, they are vulnerable to adverse events, which may result in recurrent hospitalization (the post-hospital syndrome).1 In theory, providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. Within the United States, home health care (HHC) referrals after acute care hospitalization increased by 65% to 3.7 million between 2001 and 2012.2,3 Patients discharged from US hospitals with a primary diagnosis of HF had the highest number of HHC referrals during this time, with ≈200 000 post-acute HHC referrals in 2012.2 In addition, HHC surpassed skilled nursing facilities as the most frequently used post-acute care among Medicare beneficiaries with HF in 2012 (unpublished HCUPnet data). Such an increase in HHC use for patients with HF is likely related to multiple factors, including decreasing length of stay for patients with HF4 and more recent pressures to improve readmission rates for HF after adoption of the Affordable Care Act in 2010, which included the Hospital Readmissions Reduction Program that was implemented in 2012.5,6 Despite substantial growth in post-acute HHC referrals for patients with HF,2 it is unclear whether HHC delivered in real-world settings consistently provides high-value care. Understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care. Because most patients referred for skilled HHC are Medicare beneficiaries, Medicare eligibility and payment policies have important implications for HHC. Patients who …

The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

Wide Variation In Episode Costs Within A Commercially Insured Population Highlights Potential To Improve The Efficiency Of Care

Reforming payment methods to move away from fee-for-service reimbursement is widely seen as a crucial step toward controlling health care costs. Although there is a good deal of evidence about variability in costs under Medicare, little has been published about the variability of costs for care that is financed by private insurance. We examined both quality and actual medical costs for episodes of care provided by nearly 250,000 US physicians serving commercially insured patients nationwide. Overall, episode costs for a set of major medical procedures varied about 2.5-fold, and for a selected set of common chronic conditions, episode costs varied about 15-fold. Among doctors meeting quality and efficiency benchmarks, however, costs for episodes of care were on average 14 percent lower than among other doctors. Some markets exhibited much higher variation in episode costs, but there was essentially no correlation between average episode costs and measured quality across markets. The overall analysis suggests that changing incentives through payment reforms could help to improve performance, but providers are at different stages of readiness for such reforms and thus will often need support in order to succeed.

Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer

Objective The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types. Methods A retrospective claims analysis was performed on Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population between October 1, 2004 and September 30, 2006. The insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC. Results Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. Conclusions Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.