Facility Fees Research Articles

Where Is the Value in Ambulatory Versus Inpatient Surgery?

The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures. Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery. All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Inverse probability of treatment weighting-adjusted gamma generalized linear and logistic regression was employed to compare costs and 30-day readmission between inpatient and ambulatory-based surgery, respectively. Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (P < 0.001 for all). Adjusted odds of experiencing a 30-day readmission after thyroidectomy [odds ratio (OR) 0.70, 95% confidence interval (CI), 0.53-0.93; P = 0.03], hernia repair (OR 0.28, 95% CI, 0.20-0.40; P < 0.001), and laparoscopic cholecystectomy (OR 0.37, 95% CI, 0.32-0.43; P < 0.001) were lower in the ambulatory versus inpatient setting. Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (OR 0.63, 95% CI, 0.31-1.26; P = 0.19). Ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.

The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review

BackgroundThe increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness.MethodsThe sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software.ResultsNine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate.ConclusionsThe effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes.

Economic Burden of Out-of-Pocket Spending for Plastic Surgery Procedures: Value From the Patient’s Perspective

PURPOSE: Health insurance reimbursement structure has evolved with patients becoming increasingly responsible for their healthcare costs through rising out-of-pocket (OOP) expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients.1,2 Given the possible negative effects of OOP expenses on the patient, we aim to investigate temporal trends in OOP expenses for plastic and reconstructive surgical procedures and determine drivers for increased cost sharing. METHODS: The study cohort comprised of patients undergoing the most common outpatient reconstructive plastic surgeries (skin cancer excision with closure, breast reconstruction, breast reduction, hand surgery, facial fracture repair, and scar revision/complex closure),3 using Truven MarketScan databases from 2009 to 2017. Sociodemographic characteristics, insurance type, and outpatient surgery location data were collected. Total cost of the surgery paid to the insurer and OOP expenses, including deductible, copayment, and coinsurance, were examined over time. OOP expenses were investigated using multivariable generalized linear modeling with log link and gamma distribution. All costs were inflation adjusted to 2017 dollars. RESULTS: We evaluated 3,181,125 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. The adjusted mean total cost in 2009 was $1,055 and in 2017 was $1,338 (increase in 27%), and the adjusted mean OOP expenses in 2009 were $121 and in 2017 were $184 (increase in 52%). Patients undergoing hand surgical procedures had the largest increase in total cost ($1,776 in 2009 to $2,545 in 2017, increase of 43%, P < 0.001) and OOP expenses ($197 in 2009 to $331 in 2017, increase of 68%, P < 0.001). Procedures performed in ambulatory surgical centers accounted for the largest increase in cost sharing between 2009 and 2017 (increase of 74%), but total costs only increased 24%. Facility fees were $385 on average in 2009 compared to $704 in 2017 (P < 0.001), and mean professional fees were $538 in 2009 compared to $635 in 2017 (P < 0.001). In the adjusted regression, managed care, Medicare-managed care, and Medicare-fee-for-service had approximately 42%–64% of the OOP expenses compared to fee-for-service insurance (P < 0.001). CONCLUSION: For outpatient plastic surgery procedures, OOP expenses are increasing at a faster rate than total costs. Wide variability in cost sharing was seen across the different plastic surgery procedures, surgical location, and insurance type. For outpatient plastic surgical care that is largely elective, these temporal trends in OOP expenses must be explored and should be incorporated in the decision-making process for surgery. Given the increased scrutiny placed on rising healthcare costs, policy makers should consider the impact of cost sharing and the financial burden placed on the patient when discussing value-based reimbursement reform. REFERENCES: 1. Adrion ER, Ryan AM, Seltzer AC, et al. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176:1325–1332. 2. Ubel PA, Abernethy AP, Zafar SY. Full disclosure--out-of-pocket costs as side effects. N Engl J Med. 2013;369:1484–1486. 3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. 2017. Available at https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed February 21, 2019.

National cancer expenditure analysis in the United States Medicare population, 2013.

6647 Background: Cancer is the second leading killer in the United States, but there is no comprehensive analysis evaluating total cancer costs by cancer and treatment modality. Methods: Data from the 2013 inpatient (100%), outpatient (100%), and carrier (5%) Medicare Limited Data Set Standard Analytic Files were queried for claims filed for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for all cancer diagnoses. Claims associated with the ICD-9 codes for professional fees were analyzed by Current Procedure Terminology (CPT) code to determine resource allocation by disease. Outpatient oral chemotherapy costs were obtained from the National Average Drug Acquisition Cost database for 50 drugs used for cancer treatment in 2013. Results: $27.9 billion was spent on cancer treatment of which $12 billion (43%), $6.5 billion (23%), and $1.1 billion (4%) was allocated to professional, inpatient facility, and outpatient facility fees, respectively. Oral and hospital-based chemotherapy accounted for 17% ($4.7 billion) and 15% ($4.3 billion) of all cancer costs, respectively. Lung/thoracic cancer ($2.9 billion) had the highest total annual cost and multiple myeloma ($9,019, SD $19,962) is the most expensive cancers to treat annually per patient. Average out-of-pocket expenses are $470 (SD 287), which is 12% of the annualized per patient costs. Conclusions: In 2013, cancer accounted for only 5% of Medicare spending. Chemotherapy costs accounted for approximately a third of total spending and are likely to rise as innovation continues. Out-of-pocket spending can place a financial burden on cancer patients requiring more expensive treatments.

ANALISIS BIAYA DAN PENDAPATAN USAHA PEDAGANG SAYURAN DI PASAR TAMIN KOTA BANDAR LAMPUNG

This study aims to analyze the cost structure and the income level of vegetable traders in Tamin Market Bandar Lampung City. This research is conducted in purposively chosen Tamin Market with the consideration that Tamin Market is a center of vegetable trade and the main market in Bandar Lampung City. The data were collected in March 2017 and respondents were 15 vegetable traders who are willing to be interviewed, consisting of five stall traders, five los traders, and five street traders. Data are analyzed descriptively using qualitative and quantitative of cost and income analysis. The result showed that the traders' business cost structure consists of fixed cost and variable cost. The propotion of variable cost is higher than the fixed cost, which is 99 percent of total cost. Variable costs include plastic cost, vegetable purchase, transport, labor, and information. And fixed costs include rent cost, electricity and market facility fees. The average income of stall traders is higher than the loser traders and the street traders. The average income of stall traders is Rp817,055.00 per day, los traders is Rp737,604.00 per day, and street traders is Rp183,455.00 per day.Key words: cost structure, the level of income, vegetable traders

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

BackgroundFederally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools.ExperienceThere was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH.RecommendationsWe make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs’ Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.

Dupuytren Disease: Is Collagenase Better Than Needling?: Commentary on an article by Joakim Strömberg, MD, et al.: "Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture. A Randomized Controlled Trial with a Two-Year Follow-up".

Commentary Strömberg et al. have presented the results of a fascinating study designed to determine the outcomes of treating Dupuytren disease with either collagenase or percutaneous needle fasciotomy (PNF). This is an important topic, of special interest to hand surgeons but also to the broader orthopaedic community because these kinds of analyses of 2 different treatment modalities are a crucial element in determining treatment value. Increasingly, proof of that value has become linked to reimbursement for treatment by both government and private payers. The authors made several noteworthy conclusions. First, they found no significant differences in outcomes between the 2 groups. Second, by 2 years after treatment, one-half of the cords crossing the proximal interphalangeal joints had disappeared. Third, using what I believe are flawed calculations, the authors considered the “cost” of using collagenase to be nearly 3 times the “cost” of PNF. Collagenase has been compared with needle aponeurotomy (also termed percutaneous needle fasciotomy [PNF]) before, with prior reports showing 1-year1 and 2-year2 follow-up data. Strömberg et al. presented 2-year follow-up data in more detail. One of the important aspects of this study is that all treatment was rendered by a single surgeon (J.S.). That could be a strength because it ensures consistent treatment, but it is more likely a weakness because it means that one cannot necessarily generalize the findings to a larger population or other centers. Additional study will be needed to resolve this. The finding that the proximal interphalangeal joint contractures improved in both groups even though the treatment was delivered at the level of the metacarpophalangeal (MCP) joint warrants special consideration. It was hypothesized that this might be because once the tension in the Dupuytren cord is removed, the cord tissue resorbs. Skov et al.2 proposed a similar theory. It is intriguing to theorize this treatment effect, but there is no proof; perhaps further study will substantiate or refute that hypothesis. Strömberg et al. calculated that the cost of collagenase was nearly 3-fold higher than that of PNF at their institution. That analysis is flawed. There are a facility fee and costs of other supplies and personnel if PNF is performed in a surgery center. In contrast, collagenase is designed to be used in an office setting so those additional costs are eliminated. The adverse effects of injecting collagenase have been reported on extensively, including in the trials conducted to gain Food and Drug Administration (FDA) approval for use in the U.S. Most of those “adverse” effects are inherent to any procedure for Dupuytren disease. Pain, swelling, and bruising are expected after surgical procedures regardless of whether they are percutaneous or open, but investigators were required to report them as “complications” in the Collagenase Option for the Reduction of Dupuytren’s (CORD) I and II studies3,4, for example. It is unfortunate that Strömberg et al. did not report on adverse effects because it would have been useful to note any important differences between the 2 treatment modalities along these lines. The technique used by Strömberg et al. included injecting methylprednisolone at the same time that the PNF was done. The effect of the steroid is another variable that was not controlled and therefore another open question requiring further study. The best treatment for Dupuytren contractures continues to be fiercely debated. Recently, this was reported by McMillan et al.5 and generated discussion among hand surgeons in an open forum format online (www.assh.org). The addition of the data presented by Strömberg et al. is extremely valuable in helping to clarify the issue. What is known is that Dupuytren disease is progressive. What is unknown is the pace of the progression; that is unique to each patient and even to each extremity of each patient. “Best” treatments remain uncertain. Someday, we may have a better biological solution to the disease, whether through injections or gene therapy. For now, we can continue on our quest to discern the ideal treatment for individual patients, understanding the pros and cons of each modality.

Cost-Effective Management of Stenosing Tenosynovitis

Stenosing tenosynovitis (STS) is a common condition treated by hand surgeons. Limited evidence exists to support the nonsurgical management of STS. The purpose of this study was to prospectively evaluate a cohort of patients with STS, and to determine the strategy for treating patients with this condition that is most cost effective in terms of dollars reimbursed by payers. Prospective data were collected on patients diagnosed with STS between March 2014 and September 2014. All patients were initially treated with a corticosteroid injection. Patients with persistent symptoms were given the option of injection or surgery. A maximum of 3 injections were offered. All patients were evaluated every 6 months through office appointments or phone calls. A cost analysis was performed in our cohort using actual reimbursement rates for injections, initial and established patient visits, and facility and physician fees for surgery, using the reimbursement rates from the 6 payers covering this patient cohort. Cost savings were calculated based on offering 1, 2, and 3 injections. Eighty-eight digits in 82 patients were followed for an average of 21.9 months (range, 18.7-22.7 mo) after an initial corticosteroid injection. Thirty-five digits went on to surgical release, whereas 53 digits were treated nonsurgically. Had all patients initially undergone surgery, the cost would have totaled $169,088.98 ($1,921 per digit). Offering up to 3 injections yielded a potential savings of $72,730 ($826 per digit) or 43% of the total cost. For the 33 patients who underwent more than 1 injection, offering a second injection yielded potential savings of $15,956 ($484 per digit, 22.7%), and for the 7 patients presenting a third time, a third injection saved $1,986 ($283 per digit, 14.5%). Based on the data from our cohort, the efficient way to treat STS in terms of health care dollars spent is to offer up to 3 injections before surgical release. The first injection had the highest component of cost savings, at $826 per digit. Economic/Decision Analysis III.

Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia

Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. We constructed a decision-analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. Effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP= $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.

When Hotelling meets Vickrey. Service timing and spatial asymmetry in the airline industry

This paper analyzes rivalry between transport facilities in a model that includes two sources of horizontal differentiation: geographical location and departure time. We explore how both sources influence facility fees and the price of the service offered by downstream carriers. Travelers’ costs include a fare, a transportation cost to the facility and a schedule delay cost. The interactions in the facility-carrier model are represented as a sequential three-stage game in fees, times and fares. Duopolistic competition leads to an identical departure time across carriers when their operating costs do not vary with the time of day, but generally leads to distinct service times when this cost is time-dependent. We also find that higher per-passenger commercial revenue at one facility induces a lower fee charged by both facilities to their carrier and a lower fare charged by both carriers at their departure facility, while a lower marginal operating cost for one carrier implies a higher fee at its departure facility, a lower fee at the rival carrier’s facility and a lower fare at both facilities. Finally, we show that the socially optimal schedule differentiation decreases in the distance between facilities and in the unit transportation cost incurred by travelers, and increases in the unit schedule delay cost incurred by travelers as well as in the marginal time cost faced by carriers.

Safety of Short 30 Minutes Infliximab Infusion: A Pilot Study

BACKGROUND: Infliximab (IFX), a TNF-α inhibitor, plays a major role in the treatment of inflammatory bowel disease (IBD). It's typically infused over 2 hours, progressively increasing the infusion rate to a maximum rate of 160ml/hr. This slow infusion was adopted because of concerns for infusion reactions. However, this strategy increases both direct cost (cost per hour of infusion, facility fee, nurse time) and indirect costs (patient time away from work and family). Our pilot study aimed to assess the safety of a shortened 30 min. infusion protocol of IFX. METHODS: Patients followed at MedStar Georgetown University, who were on a stable maintenance dose of IFX and who had no history of infusion reaction to standard 2hrs IFX infusion were offered to change their infusion time to 30min. We assessed the occurrence of adverse reactions during the infusion and up to 30 days after IFX infusions. Reactions were further classified as drug related or infusion related. We present the data of our 6 months experience with short infusion (i.e. after an average of 3-4 infusions per patient) RESULTS: Of 121 IBD patients receiving IFX at our institution during the last year, 46 (38%) received 30 min. short infusions and 75 (62%) received standard infusions. Maintenance dose of IFX ranged from 5 mg/kg (69% of patients) to 7.5-10mg/kg (31%). Adverse reactions were reported in a total of 10 patients (8.3%), 4 of which in the short infusion group. A total of 5 patients, 3 of which had short infusion, had drug induced paradoxical psoriasis. Five patients had an infusion reactions: 3 had cardiovascular events (high blood pressure, tachycardia) of which 1 had received a short infusion, and 2 had self limited skin rash. None of these infusion reactions were deemed severe and none lead to a change in the subsequent infusion rate. Correlation studies were performed and no correlation was found between the incidence of adverse events and IFX infusion rate, IFX dose, and duration of IFX therapy before the reaction occurred (n=0.893). CONCLUSION(S): Short 30 minute IFX infusions in selected patients who are on a stable dose of IFX and have no history of infusion reaction during standard 2hrs infusions were well tolerated and were not associated with an increased incidence of adverse reactions. Further studies on a larger group of patients and for a longer period are needed to confirm these findings. Reduction of infusion time will decrease direct and indirect cost of therapy and improve patient experience.

Global bromine market estimated to reach $2.7 bn by 2025

Biliary strictures after orthotopic liver transplantation (OLT) are typically managed by sequential ERCP procedures, with incremental dilation of the stricture and stent exchange (IDSE) and placement of new stents. This approach resolves >80% of strictures after 12 months but requires costly, lengthy ERCPs with significant patient radiation exposure. Increasing awareness of the harmful effects of radiation, escalating healthcare costs, and decreasing reimbursement for procedures mandate maximal efficiency in performing ERCP. We compared the traditional IDSE protocol with a sequential stent addition (SSA) protocol, in which additional stents are placed across the stricture during sequential ERCPs, without stent removal/exchange or stricture dilation.Patients undergoing ERCP for OLT-related anastomotic strictures from 2010 to 2016 were identified from a prospectively maintained endoscopy database. Procedure duration, fluoroscopy time, stricture resolution rates, adverse events, materials fees, and facility fees were analyzed for IDSE and SSA procedures.Seventy-seven patients underwent 277 IDSE and 132 SSA procedures. Mean fluoroscopy time was 64.5% shorter (P < .0001) and mean procedure duration 41.5% lower (P < .0001) with SSA compared with IDSE. SSA procedures required fewer accessory devices, resulting in significantly lower material (63.8%, P < .0001) and facility costs (42.8%, P < .0001) compared with IDSE. Stricture resolution was >95%, and low adverse event rates did not significantly differ.SSA results in shorter, cost-effective procedures requiring fewer accessory devices and exposing patients to less radiation. Stricture resolution rates are equivalent to IDSE, and adverse events do not differ significantly, even in this immunocompromised population.

Coblation versus other surgical techniques for tonsillectomy.

Coblation versus other surgical techniques for tonsillectomy.

Liver transplant–related anastomotic biliary strictures: a novel, rapid, safe, radiation-sparing, and cost-effective management approach

Biliary strictures after orthotopic liver transplantation (OLT) are typically managed by sequential ERCP procedures, with incremental dilation of the stricture and stent exchange (IDSE) and placement of new stents. This approach resolves >80% of strictures after 12 months but requires costly, lengthy ERCPs with significant patient radiation exposure. Increasing awareness of the harmful effects of radiation, escalating healthcare costs, and decreasing reimbursement for procedures mandate maximal efficiency in performing ERCP. We compared the traditional IDSE protocol with a sequential stent addition (SSA) protocol, in which additional stents are placed across the stricture during sequential ERCPs, without stent removal/exchange or stricture dilation. Patients undergoing ERCP for OLT-related anastomotic strictures from 2010 to 2016 were identified from a prospectively maintained endoscopy database. Procedure duration, fluoroscopy time, stricture resolution rates, adverse events, materials fees, and facility fees were analyzed for IDSE and SSA procedures. Seventy-seven patients underwent 277 IDSE and 132 SSA procedures. Mean fluoroscopy time was 64.5% shorter (P< .0001) and mean procedure duration 41.5% lower (P< .0001) with SSA compared with IDSE. SSA procedures required fewer accessory devices, resulting in significantly lower material (63.8%, P< .0001) and facility costs (42.8%, P< .0001) compared with IDSE. Stricture resolution was >95%, and low adverse event rates did not significantly differ. SSA results in shorter, cost-effective procedures requiring fewer accessory devices and exposing patients to less radiation. Stricture resolution rates are equivalent to IDSE, and adverse events do not differ significantly, even in this immunocompromised population.

Assessment of reimbursement in a community hospital-based pharmacist-managed outpatient transition clinic.

The assessment of reimbursement for and time spent on patient visits in a newly implemented, outpatient pharmacist-managed transition clinic (TC) was studied. A retrospective chart review was conducted on clinic visits that occurred during January 1 to December 31, 2015. Patients who had at least one TC visit during the study period were included. Any visit with no response from insurance by March 31, 2016, was excluded. Services provided by the TC were billed using a facility fee billing model. The following data were collected: number of visits, time length of individual visits, billed amount, level of service, type of insurance, and amount reimbursed (from primary insurance, secondary insurance, and total amount). Data were analyzed using descriptive statistics. One hundred eight patients were eligible for inclusion in the study, with a total of 306 eligible visits. Each patient had a mean of 2.82 visits. The mean ± S.D. time spent per visit was 55 minutes. Visits were billed at level 2 (2%), level 3 (36%), and level 4 (62%). Two hundred seventy-two visits (89%) were partially or completely reimbursed by insurance, whereas 34 visits (11%) provided no reimbursement. The mean ± S.D. reimbursement was $99 ± $51.88 per visit. A pharmacist-managed TC service based in a community hospital achieved a positive return on investment through insurer reimbursement over a 12-month period.

0635 FEASIBILITY OF DRUG INDUCED SEDATION ENDOSCOPY IN THE BRONCHOSCOPY SUITE

Patients with obstructive sleep apnea (OSA) commonly experience difficulty tolerating positive airway pressure (PAP) therapy. Drug Induced Sedation Endoscopy (DISE) assesses airway characteristics while the patient is sedated and may help guide alternative interventions for OSA. Since DISE is performed in the operating room, its cost is high and its availability limited to the surgeon’s busy schedule. Performing DISE in the bronchoscopy suite may reduce cost and improve access to care while maintaining a low risk for complications. Following training by an ENT physician, a sleep boarded pulmonologist performed DISE in the bronchoscopy suite. Patients with OSA and difficulty tolerating PAP therapy were evaluated for alternative interventions via DISE. A propofol infusion was administered by an anesthesiologist trained on performing DISE and sedation level was tracked via Bispectral IndexTM for a target level of 60–75. Videos of the DISE were recorded for multidisciplinary conference review with ENT and to track patient outcomes following interventions. Baseline polysomnography prior to DISE was reviewed to classify severity of OSA. Complication rates were tracked. Facility costs of DISE in the bronchoscopy suite were compared to those of the operating room. The sleep trained pulmonologist performed 21 DISE procedures in the bronchoscopy suite over a period of ten months. Review of polysomnography prior to DISE demonstrated an average AHI of 34.3+/-15.9 and an average SpO2 nadir 78 +/- 8.3%. No complications were observed during DISE. The facility fee for performing DISE procedures in the operating room was twice as much as the facility fee for performing DISE in the bronchoscopy suite while the operator charges were the same. Based on these findings, performance of DISE in the bronchoscopy suite appears feasible, safe and cost effective. Its performance by the sleep trained pulmonologist may improve access to care and may help identify successful alternative treatments for patients with PAP intolerance. Further studies are needed to identify the training necessary for pulmonary based sleep specialists to become proficient in the procedure. None

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

The Society of Surgical Oncology and American Society of Radiation Oncology consensus statement was the first professional guideline in breast oncology to declare "no ink on tumor" as a negative margin in patients with stages I/II breast cancer undergoing breast-conservation therapy. We sought to analyze the financial impact of this guideline at our institution using a historic cohort. We identified women undergoing re-excision after breast-conserving surgery for invasive breast cancer from 2010 through 2013 using a prospectively maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis. Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with ductal carcinoma in situ. A subcohort of 83 patients (32.7%) who underwent breast-conservation therapy for stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure, per the Society of Surgical Oncology and American Society of Radiation Oncology guideline. The majority had invasive ductal carcinoma (n= 70 [84.3%]) and had invasive disease (n= 45 [54.2%]), and/or ductal carcinoma in situ (n= 49 [59.0%]) within 1 mm of the specimen margin. Seventy-nine patients underwent 1 re-excision and 4 patients underwent 2 re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations. Implementation of the Society of Surgical Oncology and American Society of Radiation Oncology consensus guideline holds great potential to optimize resource use. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Additional analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

Cost Analysis of a Multidisciplinary Aerodigestive Clinic: Are Such Clinics Financially Feasible?

Multidisciplinary clinics offer important value to pediatric patients with complex conditions that overlap specialties; however, such labor-intensive clinics are difficult to facilitate. We performed a cost analysis of our pediatric multidisciplinary aerodigestive clinic (MADC) to assess its financial feasibility at our tertiary care institution. Revenue was based on net collections for clinic, professional, and hospital setting charges generated during 12 consecutive monthly MADCs beginning August 2013. Clinic charges included facility and speech pathologist fees. Professional charges included clinic and operative fees generated by providers and anesthesiologist. Hospital setting fees included facility and material charges for technical procedures. Direct expense calculations included all providers and staff salaries, benefits, and supply costs. Charge capture for 54 consecutive patients seen during the study time included new visits 99203-99205 (n = 63), consults 99243-99245 (n = 60), and follow-up visits 99212-99215 (n = 196). Sixty percent of patients underwent a clinic nasopharyngeal or laryngeal endoscopy (92511 or 31575), and 60% underwent subsequent intraoperative procedures with 1 (n = 8) or 2 to 3 services (n = 24). Program net revenue totaled $828 136 and direct costs $518 867, accounting for a net positive margin of $309 269. When including direct downstream revenue, our MADC operates on a net positive margin, making it financially feasible.

Cost Comparison of Outpatient Versus Inpatient Unicompartmental Knee Arthroplasty.

Background:Outpatient unicompartmental knee arthroplasty (UKA) has been shown to be safe and feasible when compared with inpatient surgery; however, no studies have evaluated the cost-effectiveness and cost-benefit of performing outpatient versus inpatient UKA.Hypothesis:Significant cost savings can be achieved by transitioning UKAs from an inpatient to an outpatient procedure in an outpatient surgical facility, with no appreciable difference in complication or readmission rates.Study Design:Economic and decision analysis; Level of evidence, 3.Methods:A retrospective chart review of 25 consecutive medial UKAs was performed. A total of 10 inpatient UKAs with a mean length of stay of 1.6 days (range, 1-4 days) and 12 outpatient UKAs were included in the final analysis. A simple difference in costs incurred, reimbursements, and percentage difference between inpatient and outpatient surgery in an outpatient surgical facility was calculated. Charges were subdivided into surgical facility fees, inpatient room charges, operating room supply fees, and other fees. Secondary outcome measures included reason for greater than 1 day stay for the inpatient UKAs, complications, readmissions, and the type of regional anesthesia utilized.Results:The outpatient UKA charges were a mean $20,500 less per patient than the inpatient average charge of $46,845. The primary cost savings were attributed to the outpatient surgical facility fee, which averaged $3800 per patient, while the inpatient facility charge was 350% more expensive at $13,200 per patient (approximately $9500 savings). On the inpatient side, the average reimbursement was 55% of charges, or $25,550. For outpatient procedures, the average reimbursement was 47%, or $12,370. There was no difference between the inpatient and outpatient groups in terms of complications or readmissions.Conclusion:This work demonstrated that significant cost savings of roughly 50% can be achieved with an outpatient UKA protocol done at an outpatient surgical facility. Not only is it feasible and economically attractive to perform outpatient UKA, but it can reduce inpatient bed occupancy and resource allocation for a busy hospital.

Community that pays together stays together: Sharing of resources for colorectal cancer screening and treatment of the underserved population.

561 Background: Bridging disparities to increase colorectal cancer (CRC) screening and treatment can be expensive and time consuming. This insurmountable cost often limits care; however, for every $1 spent on cancer screening $22.37 is saved on treatment costs and economic benefits. By finding cancer through free screening initiatives for the public, a new problem arises of how to fund further treatment. Methods: Project goals are to increase screening rates and knowledge about CRC and screening in our medically underserved region. The project provides screening at no cost, but these unfunded patients do not have coverage to treat their cancer diagnosis. By establishing partnerships with home health organizations, hospital CEOs, federally qualified health centers, locally elected officials, department of public health employees, and healthcare professionals our project has navigated patients through screening and treatment free of charge by encouraging community sharing of resources. Community relationships have been nurtured by utilizing quarterly program meetings, educational outreach for providers with CME credit, and cancer symposiums. This outreach provides an open forum to ask for feedback and coordinate care for the community with a primary focus on population healthcare management. Results: In addition to the many precancerous lesions removed, two cases were identified that needed further cancer treatment. The first patient did not qualify for county indigent clinic care. One private hospital waived the facility fees and we waived the surgeon fees, and the local cancer center agreed to cover adjuvant chemotherapy costs. Another patient was navigated to a local indigent care clinic, with CT scans paid by another nonprofit organization. This patient received surgery at no cost from the surgeon or hospital. These illustrations reflect community involvement in sharing cost for the uninsured. Conclusions: Utilizing cost and resource sharing through patient navigation can lessen the financial burden of caring for uninsured patients. By focusing on community relationships, our project is overcoming limitations to provide comprehensive care for patients.