Facility Payments Research Articles

Facility Payments for Similar Procedures Performed on Men Versus Women

Facility Payments for Similar Procedures Performed on Men Versus Women

Direct Economic Burden of Cubital Tunnel Surgery in the United States: Total Payments and Components of Cost

Despite its widespread prevalence, the cost of cubital tunnel syndrome (CuTS) in the United States to patients and insurers is not well understood. The purpose of this study was to quantify the direct payments associated with operative treatment of CuTS. We hypothesized that CuTS represents a substantial cost to the payer in facility fees, surgeon fees and other expenses. Utilizing the MarketScan database of insured patients (commercial and Medicaid), we identified a cohort of 41,777 patients aged 18-64 years with surgically treated CuTS from 2006 to 2018. We estimated the median 90-day payments from encounters associated with cubital tunnel release (CuTR) and/or ulnar nerve transposition surgery by summing all payments for claims within 90 days after the index surgery. Published estimates of the annual number of cubital tunnel surgeries were used to calculate the annual expenditure. Of 41,777 patients, the median (interquartile range [IQR]) values of total direct payments were $5,522 [$3,426, $9,541]. With an estimated 94,645 cases/year, this leads to an annual payment of more than $522 million. Index facility payments (median[IQR] $2,555 [$1,359, $4,708] were the highest, followed by index provider payments ($1,691 [$1,328, $2,217]). The median index surgeon payment (median[IQR] $905 [$707, $1,184]) represented just over half of the provider payments. Post-operative care had a median [IQR] payment of $377 ($424, $1,987). Limitations of claims databases prevented assessment of other indirect costs associated with cubital tunnel surgery. Payments for the surgical treatment of CuTS from the index surgery to 90 days post-operatively have an estimated median of $5,522 per patient, totaling $52 million annually. Index facility fees are responsible for more than 46% of payments, while index payments to surgeons represent approximately 16%. Defining this data is critical to understanding one component of the economic impact of CuTS. Level IV.

Oregon's Hospital Payment Cap and Enrollee Out-of-Pocket Spending and Service Use

Enrollee cost-sharing and health insurance premiums have grown alongside rising hospital prices. To control prices and price growth, the Oregon State Employee plan instituted a cap on hospital facility payments in October 2019 that was found to reduce hospital prices. Yet the program's association with out-of-pocket spending and use among enrollees is unknown. To assess the association of the Oregon State Employee Plan's hospital payment cap with out-of-pocket spending and changes in service use among state employees enrolled in higher cost-sharing plans. Using data from the Oregon All Payer All Claims database (January 2014 to December 2021), a difference-in-differences analysis was conducted to examine the association of Oregon's hospital payment cap with enrollee out-of-pocket spending and service use. The main analysis focused on the outpatient setting, where there were significant declines in hospital prices. Changes in a subpopulation of employees enrolled in higher cost-sharing plans were also examined. The primary outcome was outpatient out-of-pocket spending per procedure, which included the copayment, coinsurance, and/or deductible paid at the point of service. Changes in service use were also examined by counting the number of outpatient procedures received per enrollee per year. The outpatient sample included 1 094 083 procedures from 92 523 Oregon educators and 4 510 342 procedures from 473 621 control enrollees. During the period before implementation, Oregon educators had higher out-of-pocket spending per outpatient procedure than the control group ($69.26 vs $41.87). The hospital payment cap was associated with a $6.60, or 9.5%, reduction in out-of-pocket spending per procedure (95% CI, -12.7 to -0.5) and a 0.24, or 4.8%, increase in the number of outpatient procedures received per enrollee per year (95% CI, 0.09-0.39) among those in higher cost-sharing plans. Enrollees receiving outpatient services from October 2019 through December 2021 saved an estimated $1.8 million. However, savings for the state were $10.3 million less than they would have been absent increases in service use. The study findings suggest that enrollees may benefit from reduced out-of-pocket spending due to hospital price regulations, but states should be mindful that price regulations may inadvertently increase health care service use.

Free Flap Reconstruction in the Era of Commercial Price Transparency: What Are We Paying For?

Commercial rates for free flap reconstruction were not known publicly before the 2021 Hospital Price Transparency Final Rule. The purpose of this study was to examine commercial facility payments to characterize nationwide variation for microsurgical operations and identify opportunities to improve market effectiveness. A cross-sectional study was performed using 2022 commercial insurance pricing merged with hospital performance data. Facility payment rates were extracted for nine CPT codes for free flap operations. Price variation was quantified by means of across-hospital ratios and within-hospital ratios. Mixed effects linear models evaluated commercial rates relative to value, outcomes, and equity performance metrics, in addition to facility-level factors that included health care market concentration. A total of 20,528 commercial rates across 675 hospitals were compiled. Across-hospital ratios ranged from 5.85 to 7.95, whereas within-hospital ratios ranged from 1.00 to 1.71. Compared with the lowest scoring hospitals (grade D), hospitals with an outcome grade of A and equity grades of B or C were associated with higher commercial rates ( P < 0.04); there were no significant differences in rate based on value. Higher commercial rates were also associated with nonprofit status and more concentrated markets ( P < 0.006). Lower commercial rates were correlated with safety-net and teaching hospitals ( P < 0.001). Commercial rates for free flaps varied substantially both across and within hospitals. Associations of higher commercial rates with less competitive markets, and the lack of consistent association with value and equity, identify market failures. Additional work is needed to improve market efficiency for free flap operations.

The Cost of Standard and Complex Pars Plana Vitrectomy for Retinal Detachment Repair Exceeds Its Reimbursement

To measure the total costs and reimbursements associated with standard and complex pars plana vitrectomy using time-driven activity-based costing (TDABC). Economic analysis at a single academic institution. Patients who underwent standard or complex pars plana vitrectomy (PPV; Current Procedural Terminology codes 67108 and 67113) at the University of Michigan in the calendar year2021. Process flow mapping for standard and complex PPVs was used to determine the operative components. The internal anesthesia record system was used to calculate time estimates, and financial calculations were constructed from published literature and internal sources. A TDABC analysis was used to determine the costs of standard and complex PPVs. Average reimbursement was based on Medicare rates. The primary outcomes were the total costs for standard and complex PPVs and the resulting net margin at current Medicare reimbursement levels. The secondary outcomes were the differential in surgical times, costs, and margin for standard and complex PPV. Over the 2021 calendar year, a total of 270 standard and 142 complex PPVs were included in the analysis. Complex PPVs were associated with significantly increased anesthesia time (52.28 minutes; P < 0.001), operating room time (51.28 minutes; P < 0.0001), surgery time (43.64 minutes; P < 0.0001), and postoperative time (25.95 minutes; P < 0.0001). The total day-of-surgery costs were $5154.59 and $7852.38 for standard and complex PPVs, respectively. Postoperative visits incurred an additional cost of $327.84 and $353.86 for standard and complex PPV, respectively. The institution-specific facility payments were $4505.50 and $4935.14 for standard and complex PPV, respectively. Standard PPV yielded a net negative margin of-$976.93, whereas complex PPV yielded a net negative margin of-$3271.10. This analysis demonstrated that Medicare reimbursement is inadequate in covering the costs of PPV for retinal detachment, with a particularly large negative margin for more complex cases. These findings demonstrate that additional steps may be necessary to mitigate adverse economic incentives so that patients continue to have timely access to care to achieve optimal visual outcomes after retinal detachment. The authors have no proprietary or commercial interest in any materials discussed in this article.

Current Trends in Revision Hip Arthroplasty: Indications and Types of Components Revised.

The materials and techniques for both primary and revision total hip arthroplasty (THA) have changed over time. This study evaluated if the indications for revision THA, rates of components utilized (femoral or acetabulum, both, or head/liner exchange), length of stay (LOS), and payments to surgeons and facilities have also changed. A retrospective study, utilizing the PearlDiver database, of 38,377 revision THA patients from January 2010 through December 2018 was performed. Data included the indication for revision, components revised (femoral or acetabulum, both, or head/liner exchange), LOS, and payments. Indications and components were analyzed by logistic regression (Dunnett's post hoc test). Revision totals were analyzed with a linear regression model. Analysis of variance assessed changes in LOS and payments. Patients' median age was 67 years (Q1-Q3: 59-74), and 58.7% were female. Revisions for dislocation decreased between 2010 and 2018 (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.68-0.98). Revisions for component loosening increased (OR 1.54, 95% CI 1.25-1.91). Dislocation remained the most common indication (19.3%), followed by PJI (17.3%) and loosening (17.1%). Both-component (OR:1.45; 95% CI:1.25-1.67) and femoral component only revisions increased; acetabular component only and head/liner exchanges decreased. Acetabular (OR 0.57, 95% CI 0.47-0.70) and head/liner exchange (OR 0.29, 95% CI 0.20-0.43) revisions decreased, while both component exchange (OR 1.45, 95% CI 1.25-1.67) and femoral revisions (OR 1.17, 95% CI 0.99-1.37) increased. Average LOS (-0.68 days; P < .001) and surgeon payments decreased (-$261.8; P < .001) while facility payments increased ($4,211; P < .001). Indications for revision THA in this database study changed over time, with revision for dislocation decreasing and revision for loosening increasing over time. Both component and femoral revisions increased, and acetabular component and head/liner exchanges decreased. It is possible that these associations could be attributed to a number of details, the method of femoral fixation, surgical approach, and cementing, all of which require additional study.

The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Evaluation of non-response to the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey

BackgroundThe In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey is the first patient reported outcome measure included in the U.S. Medicare End Stage Renal Disease Quality Incentive Program. Administered twice yearly, it assesses in-center dialysis experience and survey responses are tied to dialysis facility payments. Low response rates, currently approximately 35%, raise concern for possible underrepresentation of patient groups.MethodsCross-sectional analysis of survey administration in 2012 to all in-center hemodialysis patients in Dialysis Clinic, Inc. (DCI) facilities nationally over 18 years old who received hemodialysis at their facility for at least 3 months. Patient-level covariates included demographic, clinical, laboratory, and functional characteristics. Random effects multivariable logistic regression was used to assess survey non-response.ResultsAmong 11,055 eligible patients 6541 (59%) were non-responders. Of the remaining 4514 responders, 549 (14%) surveys were not usable due to presence of proxy help or incomplete responses. Non-responders were more likely to be men, non-white, younger, single, dual Medicare/Medicaid eligible, less educated, non-English speaking, and not active on the transplant list; non-responders had longer ESRD vintage, lower body mass index, lower serum albumin, worse functional status, and more hospitalizations, missed treatments, and shortened treatments. Similar associations were found using more parsimonious multivariable analyses and after imputing missing data.ConclusionsNon-responders to the ICH CAHPS significantly differed from responders, broadly spanning individuals with fewer socioeconomic advantages and greater illness burden, raising limitations in interpreting facility survey results. Future research should assess reasons for non-response to improve ICH CAHPS generalizability and utility.

Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment.

OBJECTIVE Spine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. This study is a cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. The objective was to quantify variation in payments for spine surgery in adult patients, document sources of variation, and determine influence of patient-level, surgeon-level, and hospital-level factors. METHODS Hierarchical regression models were used to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. The primary outcome was price-standardized 90-day episode payments. Intraclass correlation coefficients-measures of variability accounted for by each level of a hierarchical model-were used to quantify sources of spending variation. RESULTS The authors analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean price-standardized 90-day episode payments in the highest spending quintile exceeded mean payments for episodes in the lowest cost quintile by $42,953 (p < 0.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI 1.1%-3.8%) and 4.0% (95% CI 2.9%-5.6%) of total variation, respectively. CONCLUSIONS Significant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of the observed variation.

A Review of Initiatives that Link Provider Payment with Quality Measurement of Maternal Health Services in Low- and Middle-Income Countries

—To reduce maternal and newborn morbidity and mortality, health care payers are experimenting with ways to better align incentives to promote high-quality maternal health services. This review examined 26 recent initiatives of health care payers in 16 low- and middle-income countries to pay for quality, and not solely quantity, of maternal health services. Payers measured quality by assessing availability of structural inputs (24 of 26 cases), adherence to processes (25 of 26 cases), and observation of key outputs of health facilities (14 of 26 cases). Two payers sought to also assess quality through observed patient outcomes. In 25 of the initiatives, payers used the quality assessment to adjust facility payments; in the remaining initiative, the payer used the quality assessment to adjust payments to provincial governments, which in turn pay facilities. The recent growth in such payment systems suggests more health care payers have identified ways to link quality measurement with provider payment mechanisms. Eleven impact evaluations of systems documented changes in provider behavior consistent with various elements of quality; however, only three evaluations reported effects on maternal or newborn morbidity and mortality and do not conclude whether the design or flaws in how it was implemented led to the results. Implementation fidelity—the degree to which the initiative was implemented as designed—was not widely addressed and is an area for future research. Furthermore, although payers in low- and middle-income countries have identified ways to operationalize a payment system that adjusts payments based on some measure of quality, the complexity and level of resources required to operationalize them raise concerns about sustainability.

Effects of the Medicare Modernization Act on Spending for Outpatient Surgery.

To examine the effects of Medicare's revised ambulatory surgery center (ASC) payment schedule on overall payments for outpatient surgery. Twenty percent sample of national Medicare beneficiaries. We conducted a pre-post study of Medicare beneficiaries who underwent outpatient surgery in a hospital outpatient department (HOPD), ASC, or physician office between 2004 and 2011. Specifically, we used multivariable regression to compare temporal trends in outpatient surgery before and after implementation of Medicare's revised payment schedule in 2008, which reduced ASC facility payments to roughly two-thirds that of HOPDs. Our outcome measures included overall Medicare payments, utilization rates, per beneficiary spending, and average episode payments for outpatient surgery. Between the last quarters of 2007 and 2008, overall Medicare payments for outpatient surgery grew by $334million-an amount nearly three times higher than would have been expected without the policy change (p<.001 for the difference). While utilization rates of outpatient surgery were attenuated, per beneficiary spending and average surgical episode payments increased by 10.4 percent and 7.8 percent, respectively, over the same period. By the end of 2011, Medicare payments for outpatient surgery reached $5.1billion. Without the policy change, they would have totaled only $4.1billion. Despite lessening demand, reduced ASC facility payments did not curb spending for outpatient surgery. In fact, overall payments actually increased following the policy change, driven by higher average episode payments.

115 Variation in Payments for Spine Surgery Episodes of Care

Abstract INTRODUCTION Spine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. We sought to quantify variation in spine surgery payments, document sources of variation, and determine the influence of patient-level, surgeon-level, and hospital-level factors on payment variation. METHODS Cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. Participants were adult patients who underwent spine-based surgical procedures. We used hierarchical regression models to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. Our primary outcome was price-standardized 90-day episode payments. We used intraclass correlation coefficients measures of variability accounted for by each level of a hierarchical model to quantify sources of spending variation. RESULTS &gt;We analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean payment in highest cost quintile of episodes ($52,767; 95% CI, $52,133 to $53,401) significantly exceeded mean episode payment in lowest cost quintile ($9814; 95% CI, $9757 to $9872; P&lt;.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI, 1.1% to 3.8%) and 4.0% (95% CI, 2.9% to 5.6%) of total variation, respectively. CONCLUSION Significant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of observed variation. Our results suggest that alternative payment models applied to spine surgery including bundled payment will not be successful if their design assumes that surgeon and hospital preferences are the primary source of variation in costs.

Facility Payments for Interventional Pain Management Procedures: Impact of Proposed Rules

In the face of the progressive implementation of the Affordable Care Act (ACA), a significant regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016, and the physician payment schedule was released July 15, 2016. U.S. health care costs continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and surpassing $3 trillion in overall health care expenditure. Solo and independent practices face unique challenges and many are being acquired by hospitals or larger groups. This transfer of services to hospital settings is indisputably leading to an increase in the net cost to the system. Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office settings shows wide variation for multiple interventional techniques. Major discrepancies in payment schedules are related to higher payments for hospitals than comparable treatments in in-office settings and ASCs. In-office procedures, which have been converted to ASC procedures, are reimbursed at as high as 1,366% higher than ASCs and 2,156% higher than in-office settings. The Medicare Payment Advisory Commission (MedPAC) has made recommendations on avoiding the discrepancies and site-of-service differentials in in-office settings, hospital outpatient settings, and ASCs. These have not been implemented by CMS. In addition, there have been slow reductions in reimbursements over the recent years, which continue to accumulate, leading to significant reductions in payments In conclusion, equalization of site-of-service differentials will simultaneously improve reimbursement patterns for interventional pain management procedures, increase access and quality of care, and finally, reduce costs for CMS, extending Medicare solvency. Key words: Hospital outpatient departments, ambulatory surgery centers, physician inoffice services, interventional pain management, interventional techniques

Longitudinal Trends in Costs of Palliative Radiation for Metastatic Prostate Cancer.

In recent years, palliative treatment of prostate cancer metastases has been characterized by the use of more complex radiation treatment, despite a lack of evidence demonstrating a clinical benefit of these technologies in the palliative setting. The impact of adoption of these technologies on the costs of palliative radiation treatment in patients with metastatic prostate cancer remains poorly understood in the general patient population. The study was a retrospective analysis of Surveillance, Epidemiology and End Results (SEER) Medicare data of men aged 66 and older who died from metastatic prostate cancer between 2000 and 2007 and received radiation therapy for bony metastases in the last year of life. Direct costs were obtained from Medicare carrier and outpatient facility payments for all radiation treatment claims and adjusted to 2008 dollars. A total of 1705 men met study inclusion criteria. Total Medicare payments for radiation therapy for bony metastases in the last year of life increased by 44.4% from an average of $2,763 in 2000 to $3,989 in 2007, with the proportion of all payments accrued within hospital-based settings increasing from 48% to 57%. Complexity of radiation therapy techniques over the same period was characterized by use of less simple (30.1% to 23.3%) and more complex (59.9% versus 66.7%) radiation therapy. From 2000-2003 to 2004-2007, the use of shorter treatment courses (≤5 fractions) decreased from 22% to 14%, and the use of single fraction treatment courses decreased by half (6.3% to 2.9%; P≤.001). Between 2000 and 2007, palliative radiation therapy for bony prostate cancer metastases was characterized by the use of more advanced treatment technologies and prolonged radiation treatment courses. Further research investigating barriers to cost-effective palliation is warranted.

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Government Accepts Higher Work Values for Psychiatry Codes

Government Accepts Higher Work Values for Psychiatry Codes

Anesthesia Service Costs and Savings to Medicare From the Growth of ASCs

To the Editor: In their letter to the editor, Drs Scheiman and Domonitz question the validity of our study conclusions that continued growth in the provision of colonoscopies at Ambulatory Surgical Centers (ASCs) would result in savings to Medicare (1). Their specific criticism is that our study, which focused on facility payments, excluded ancillary costs—particularly payments for anesthesia services. Drs Scheiman and Domonitz point to work demonstrating that the use of anesthesia services during a colonoscopy is higher in ASCs than in hospital outpatient departments (HOPDs) (2). Moreover, the use of these services has grown significantly and resulted in higher Medicare payments for colonoscopy over the last several years (3). Drs Scheiman and Domonitz argued that the savings from ASCs could “rapidly dissipate” if ancillary service costs are considered because of higher utilization of these services at ASCs.

Longitudinal trends in costs for palliative radiation for metastatic prostate cancer.

6554 Background: Prostate cancer is a leading contributor to cancer health care costs, with end of life care composing a substantial portion of overall costs. In recent years, palliative treatment of metastases has been characterized by the use of more complex radiation planning and delivery systems. However, little is known about how costs of palliative radiation treatment in patients with metastatic prostate cancer have changed over this period. Methods: Retrospective analysis of SEER-Medicare data of men aged 66 and older who died from metastatic prostate cancer between 2000 and 2007. Inclusion criteria included all fee-for-service beneficiaries treated with radiation therapy for bony metastases in the last year of life. Direct costs were obtained by summing Medicare carrier and outpatient facility payments for all radiation treatment claims following an initial radiation treatment claim for bony metastases and adjusted to 2008 dollars using Consumer Price Indexes for medical care. Results: A total of 1,705 men met study inclusion criteria. Median age at diagnosis was 74, median time from diagnosis to death was 47 months, and 37% of men had distant metastatic disease at the time of diagnosis. Total Medicare payments for radiation therapy for bony metastases increased from an average of $2,763 to $3,989 for men who died from prostate cancer in 2000 vs. 2007. Outpatient facility claims for radiation therapy increased relative to carrier claims, composing 48% ($1,316) and 57% ($2,276) of all radiation treatment Medicare payments in 2000 vs. 2007 (All P &lt; 0.001). Conclusions: Between 2000 and 2007, average Medicare payments for palliative radiation therapy for bony prostate cancer metastases increased by roughly a third. The majority of increased costs were observed within outpatient facility claims, suggesting a shift in the administration of palliative radiation therapy from free-standing clinics to hospital-based outpatient facilities. Changes in end of life palliative radiation therapy for men with prostate cancer may impact future increases in Medicare health care expenditures.

Abstract 297: Trends in 1-year hospitalizations and costs from 2004 to 2010 among Medicare Fee-For-Service beneficiaries with LVADs

Background: Short-term mortality among elderly Left Ventricular Assist Devices (LVADs) recipients has improved over time, yet LVADS are expensive and usually reserved for patients with severe heart failure with few other treatment options. Little is known about the long-term illness burden of these patients and how it has changed over time with improvements in LVAD technology. The aim of this study is to characterize the duration and cost of re-hospitalizations among elderly Medicare beneficiaries surviving one year post-LVAD implant from 2004-2010. Methods: We used inpatient National Claims History files from the Centers for Medicare and Medicaid Services (CMS) to identify 100% of fee-for-service (FFS) patients aged ≥65 years that received LVAD from 2004 to 2011 and were alive 1 year after discharge. The 2011 data was used for tracking the 1-year outcomes of 2010 patients. We censored patients that died within 1-year follow-up. We ascertained hospitalizations and in-hospital days through corresponding vital status files. Costs were defined as total health care facility payments made by Medicare per patient. Results: One year post-LVAD implantation, the proportion of living patients increased from 42% (n=45/107) in 2004 to 80% (n=348/433) in 2010. The proportion of patients readmitted decreased from 71% (n= 32/45) in 2004 to 61% (n=281/348) in 2010. The mean number of in-hospital days per patient hospitalized decreased from 30.2 days in 2004 to 20.8 days in 2010. Total CMS payments for all hospitalizations per patient increased from $50,111 in 2004 to $53,632 in 2010. Conclusions: From 2004 to 2010, more patients survived to 1 year after LVAD implant. Elderly patients spent a decreasing number of days in the hospital per patient with a slight increase in costs to Medicare. This reduction in hospital days suggests a decrease in LVAD morbidity over time that is complementary to the decline in mortality among this vulnerable group of LVAD recipients.

Medicare Payments for Outpatient Urological Surgery by Location of Care

The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.