Reimbursement Schedules Research Articles

The direct costs of coronary CT angiography relative to contrast-enhanced thoracic CT: Time-driven activity-based costing

BackgroundCoronary CT angiography (CCTA) and contrast-enhanced thoracic CT (CECT) are distinctly different diagnostic procedures that involve intravenous contrast-enhanced CT of the chest. The technical component of these procedures is reimbursed at the same rate by the Centers for Medicare and Medicaid Services (CMS). This study tests the hypothesis that the direct costs of performing these exams are significantly different. MethodsDirect costs for both procedures were measured using a time-driven activity-based costing (TDABC) model. The exams were segmented into four phases: preparation, scanning, post-scan monitoring, and image processing. Room occupancy and direct labor times were collected for scans of 54 patients (28 CCTA and 26 CECT studies), in seven medical facilities within the USA and used to impute labor and equipment cost. Contrast material costs were measured directly. Cost differences between the exams were analyzed for significance and variability. ResultsMean CCTA duration was 3.2 times longer than CECT (121 and 37 ​min, respectively. p ​< ​0.01). Mean CCTA direct costs were 3.4 times those of CECT ($189.52 and $55.28, respectively, p ​< ​0.01). Both labor and capital equipment costs for CCTA were significantly more expensive (6.5 and 1.8-fold greater, respectively, p ​< ​0.001). Segmented by procedural phase, CCTA was both longer and more expensive for each (p ​< ​0.01). Mean direct costs for CCTA exceeded the standard CMS technical reimbursement of $182.25 without accounting for indirect or overhead costs. ConclusionThe direct cost of performing CCTA is significantly higher than CECT, and thus reimbursement schedules that treat these procedures similarly undervalue the resources required to perform CCTA and possibly decrease access to the procedure.

Economic Evaluation of Urine-Based or Magnetic Resonance Imaging Reflex Tests in Men With Intermediate Prostate-Specific Antigen Levels in the United States

ObjectivesFor men with intermediate prostate-specific antigen (PSA) levels (4-10 ng/mL), urine-based biomarkers and multiparametric magnetic resonance imaging (MRI) are increasingly used as reflex tests before prostate biopsy. We assessed the cost effectiveness of these reflex tests in the United States. MethodsWe used an existing microsimulation model of prostate cancer (PCa) progression and survival to predict lifetime outcomes for a hypothetical cohort of 55-year-old men with intermediate PSA levels. Urine-based biomarkers—PCa antigen (PCA3), TMPRSS2:ERG gene fusion (T2:ERG), and the MyProstateScore (MPS) for any PCa and for high-grade (Gleason score ≥7) PCa (MPShg)—were generated using biomarker data from 1112 men presenting for biopsy at 10 United States institutions. MRI results were based on published sensitivity and specificity for high-grade PCa. Costs and utilities were sourced from literature and Medicare reimbursement schedules. Outcome measures included life years, quality-adjusted life years (QALYs), and lifetime medical costs per patient. Incremental cost-effectiveness ratios were empirically calculated on the basis of simulated life histories under different reflex testing strategies. ResultsBiopsying all men provided the most life years and QALYs, followed by reflex testing using MPShg, MPS, MRI, T2:ERG, PCA3, and biopsying no men (QALY range across strategies 15.98-16.09). Accounting for costs, MRI and MPShg were dominated by other strategies. PCA3, T2:ERG, and MPS were likely to be the most cost-effective strategy at willingness-to-pay thresholds of $100 000/QALY, $125 000/QALY, and $150 000/QALY, respectively. ConclusionsUsing PCA3, T2:ERG, or MPS as reflex tests has greater economic value than MRI, biopsying all men, or biopsying no men with intermediate PSA levels.

Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020

PurposeTo investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. Materials and MethodsReimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. ResultsFrom 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by −6.9% (95% confidence interval [CI], −13.5% to −0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of −18.7% (95% CI, −24.4% to −12.9%) during the study period, with a mean yearly decline of −2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. ConclusionsIn just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.

Cost-effectiveness Analysis of Universal Cystoscopy at the Time of Benign Laparoscopic Hysterectomy

To estimate the rate of lower urinary tract injury (LUTI) and percentage of LUTI needing to be recognized intraoperatively to make universal cystoscopy cost-effective and cost-saving during laparoscopic hysterectomy. A decision tree model was used to estimate the costs and quality-adjusted life years associated with delayed or intraoperative recognition of LUTI at the time of laparoscopic hysterectomy. Probabilities and utilities were estimated from published literature. Costs were estimated from Medicare national reimbursement schedules. Threshold analyses estimated the LUTI rate and cystoscopy sensitivity that would make universal cystoscopy cost-effective or cost-saving. Monte Carlo simulations were performed. US healthcare system. Individuals undergoing laparoscopic hysterectomy for benign indications. Theoretic implementation of a universal cystoscopy policy. The total direct medical costs of laparoscopic hysterectomy under usual care were $8831 to $9149 and under universal cystoscopy were $8944 to $9068. When low LUTI rates (0.44%; estimated using sample-weighted estimates of retrospective and prospective data) were assumed, universal cystoscopy was only cost-effective in 17.1% of the simulations; the incremental cost was estimated to be $111 to $131. With median LUTI rates (2.3%) or high LUTI rates (4.0%; estimated using only prospective data with universal screening), the universal cystoscopy strategy was cost-effective in 93.9% and 99.6% of the simulations, respectively, and potentially cost-saving if the sensitivity of intraoperative cystoscopy for ureteral injury exceeded 65% or 31%, respectively. The estimated potential savings were $18 to $95 per hysterectomy. In threshold analysis assuming the average cystoscopy sensitivity rate, universal cystoscopy is estimated to be cost-effective when the LUTI rate exceeds 0.80%. In our model, universal cystoscopy is the preferred approach for laparoscopic hysterectomy and is estimated to be cost-effective in contemporary clinical settings where the LUTI rate is estimated to be 1.8% and potentially cost-saving among higher-risk populations, including those with endometriosis or pelvic organ prolapse. If the LUTI rates are less than 0.75%, the estimated incremental costs are modest-up to $131 per case. Administrators and providers should consider the local LUTI rates and practice patterns when planning implementation of a universal cystoscopy policy.

Do discontinuities in marginal reimbursement affect inpatient psychiatric care in Germany?

This paper examines the behaviour of mental health care providers in response to marginal payment incentives induced by a discontinuous per diem reimbursement schedule with varying tariff rates over the length of stay. The analyses use administrative data on 12,627 cases treated in 82 psychiatric hospitals and wards in Germany. We investigate whether substantial reductions in marginal reimbursement per inpatient day led to strategic discharge behaviour once a certain length of stay threshold is exceeded. The data do not show gaps and bunches at the duration of treatment when marginal reimbursement decreases. Using logistic regression models, we find that providers did not react to discontinuities in marginal reimbursement by significantly reducing inpatient length of stay around the threshold. These findings are robust in terms of different model specifications and subsamples. The results indicate that if regulators aim to set incentives to decrease LOS, this might not be achieved by cuts in reimbursement over LOS.

Cost-Benefit Implication of Gene Expression Profiling and Adjuvant Therapy in Stage IIIA Melanoma

Indiscriminate use of adjuvant therapy in stage IIIA melanoma is controversial. We sought to model the clinical impact and cost of implementing a gene expression profile (GEP) test to guide adjuvant therapy. A Markov decision-analysis model was created to represent resected stage IIIA melanoma with 3 treatment options: observation (OBS), adjuvant pembrolizumab for all patients (ALL), and selective adjuvant therapy (SEL). In the SEL option, only high-risk patients based on GEP stratification were treated with pembrolizumab. Cost of adjuvant therapy was normalized to reflect Medicare reimbursement schedules. The primary outcome was cost per mortality avoided at 10 years. Model projections for 10-year overall survival were 68% for OBS, 73% for SEL, and 76% for ALL. The estimated incremental cost-per-mortality-avoided (compared to OBS) was $2.1 million for SEL and $2.4 million for ALL. These translate to costs of $583.0K and $697.1K per life-year for the SEL and ALL strategies, respectively. Routine adjuvant pembrolizumab for stage IIIA melanoma is costly, and risk-stratification by GEP only marginally improves the value of therapy.

The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis.

Use of platelet-rich-plasma (PRP) injections for treating knee osteoarthritis has increased over the past decade. We used cost-effectiveness analysis to evaluate the value of PRP in delaying the need for total knee arthroplasty (TKA). We developed a Markov model to analyze the baseline case: a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis undergoing a series of 3 PRP injections with a 1-year delay to TKA versus a TKA from the outset. Both health-care payer and societal perspectives were included. Transition probabilities were derived from systematic review of 72 studies, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry, and individual costs from Medicare reimbursement schedules. Primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs) and evaluated against willingness-to-pay thresholds of $50,000 and $100,000. One and 2-way sensitivity analyses were performed as well as a probabilistic analysis varying PRP-injection cost, TKA delay intervals, and TKA outcomes over 10,000 different simulations. From a health-care payer perspective, PRP resulted in 14.55 QALYs compared with 14.63 for TKA from the outset, with total health-care costs of $26,619 and $26,235, respectively. TKA from the outset produced a higher number of QALYs at a lower cost, so it dominated. From a societal perspective, PRP cost $49,090 versus $49,424 for TKA from the outset. The ICER for TKA from the outset was $4,175 per QALY, below the $50,000 willingness-to-pay threshold. Assuming the $728 published cost of a PRP injection, no delay time that was <10 years produced a cost-effective course. When the QOL value was increased from the published value of 0.788 to >0.89, PRP therapy was cost-effective with even a 1-year delay to TKA. When considering direct and unpaid indirect costs, PRP injections are not cost-effective. The primary factor preventing PRP from being cost-effective is not the price per injection but rather a lack of established clinical efficacy in relieving pain and improving function and in delaying TKA. PRP may have value for higher-risk patients with high perioperative complication rates, higher TKA revision rates, or poorer postoperative outcomes. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PCN51 A COST-EFFCTIVENESS ANALYSIS OF PEMBROLIZUMAB PLUS AXITINIB VERSUS SUNITINIB FOR FIRST-LINE TREATMENT OF ADVANCED RENAL CELL CARCINOMA

To evaluate the cost-effectiveness of pembrolizumab plus axitinib compared with sunitinib for first-line treatment of advanced renal cell carcinoma from a third-party payer perspective in the U.S. A Markov model with a cycle length of 6 weeks was constructed to simulate three health states: progression-free, progressive disease and death. The model was run until 99% patients died. Both health outcomes and costs were discounted at an annual rate of 3%. Clinical parameters were informed by the KEYNOTE-426 trial. Cost data including drug acquisition costs, administration costs and adverse event costs were derived from government reimbursement schedules and published literature and adjusted to 2019 USD. Utility values of different health states and disutility from adverse events were obtained from published literature. Outcomes were measured as incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMBs). One-way sensitivity analysis was performed to test the robustness of the model. In the base case, pembrolizumab plus axitinib generated a gain of 3.25 life years (5.11 vs. 1.86) and 1.35 quality-adjusted life years (QALYs) (3.03 vs. 1.68) over sunitinib at an additional cost of $343,966 ($619,701 vs. $275,735), yielding an ICER of $254,987/QALY. One-way sensitivity analysis shows that results are most sensitive to median overall survival, median progression-free survival, and drug costs of the pembrolizumab plus axitinib group. Pembrolizumab plus axitinib had a higher NMB than sunitinib only at willingness-to-pay (WTP) thresholds larger than or equal to $270K/QALY. Using a WTP threshold of $150K/QALY, pembrolizumab plus axitinib is not likely to be cost effective for first-line treatment of renal cell carcinoma at current list price compared to sunitinib.

27: Costs of delayed vs intraoperative recognition of lower urinary tract injury at the time of laparoscopic hysterectomy

To evaluate the direct medical costs associated with delayed versus immediate recognition of lower urinary tract injury (LUTI) at the time of laparoscopic hysterectomy and estimate the relative costs and savings associated with universal cystoscopy (UC) as compared to selective cystoscopy (SC). A decision tree model was used to estimate the costs associated with delayed vs intraoperative recognition of LUTI at the time of laparoscopic hysterectomy for benign indications. Probability distributions of injury and its associated complications were drawn from published literature. Where multiple published probabilities were available, a sample-size-weighted average was used with a PERT distribution. Healthcare payer costs were drawn from 2016 Centers for Medicare and Medicaid Services national reimbursement schedules and included estimated physician fees, anesthesia fees, facility fees, imaging fees and pathology fees, using Current Procedural Terminology or Diagnosis Related Group codes as appropriate. The payer cost of cystoscopy was estimated using bundled outpatient reimbursement rates, as it is not separately billed at the time of hysterectomy. Total costs were estimated under both SC and UC. SC assumed an average 25% cystoscopy rate based on published literature. A three-way threshold analysis was performed to determine the proportion of LUTI with delayed diagnosis that would need to be diagnosed intraoperatively to favor UC under three scenarios: low injury rates (0.5%; estimated using pooled retrospective and prospective data), high injury rates (4%; estimated using prospective data with universal screening), and moderate injury rates (2.2%). Probabilistic sensitivity analysis was used to assess the robustness of the findings. Given insufficient data, no other healthcare system costs, such as malpractice liability, differential operating room time, or out-of-pocket expenses were included. The SC estimated cost of laparoscopic hysterectomy, inclusive of LUTI complications, ranged from $8,807 to $9,132, while the UC cost ranged from $8,962 to $9,034. Assuming high LUTI rates, UC can be cost saving with ureteral injury detection rates above 50% or bladder injury detection rates above 96%; maximal estimated costs savings were $98 per hysterectomy. UC does not achieve cost savings to the payer assuming low injury rates with a median incremental cost of $143 per hysterectomy (incremental cost to prevent one delayed diagnosis $113,186). Moderate injury rates were estimated to be cost neutral. Estimated UC costs vary based on LUTI rates, and UC policy has the potential to be cost saving through increased intraoperative diagnosis of LUTI. When not cost saving, the incremental costs of UC are modest and may still be outweighed by other health system and malpractice liability costs not accounted for within this model.

A Cost-Effectiveness and Quality of Life Analysis of Different Approaches to the Management and Treatment of Localized Prostate Cancer.

The aim of this study was to compare the cost-effectiveness and quality-adjusted life years (QALYs) of active monitoring (AM), radical prostatectomy (PR), and external-beam radiotherapy with neoadjuvant hormone therapy (RT) for localized prostate cancer. Microsimulations of radical prostatectomy, 3D-conformal radiotherapy, or active monitoring were performed using Medicare reimbursement schedules and clinical trial results for a target population of men aged 50–69 years with newly diagnosed localized prostate cancer (T1-T2, NX, M0) over a time horizon of 10 years. Quality-adjusted life years (QALYs) and costs were assessed and sensitivity analyses performed. Monte Carlo simulations revealed that the mean cost for AM, PR, and RT were $15,654, $18,791, and $30,378, respectively, and QALYs were 6.96, 7.44, and 7.9 years, respectively. The incremental cost-effectiveness ratio (ICER) was $6,548 for PR over AM and $68,339 for RT over PR. Results were sensitive to the number of years of follow-up and procedure cost. With relaxed assumptions for AM, the ICER of PR and RT met the societal willingness to pay (WTP) threshold of $50,000 per QALY. Compared with AM, PR was highly cost-effective. RT and PR for localized prostate cancer can be cost-effective, but RT must offer increased QALYs or decreased procedural costs to be cost-effective compared to PR. Newer and cheaper radiotherapy strategies like stereotactic body radiotherapy may play a crucial role in future early prostate cancer management.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model

BackgroundRecent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA). MethodsA cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion. ResultsSelective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%. ConclusionThis predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

Cost-effectiveness of axicabtagene ciloleucel for adult patients with relapsed or refractory large B-cell lymphoma in the United States

Purpose: Axicabtagene ciloleucel (axi-cel) was recently approved for treatment of relapsed or refractory (R/R) large B-cell lymphoma (LBCL) following two or more prior therapies. As the first CAR T-cell therapy available for adults in the US, there are important questions about clinical and economic value. The objective of this study was to assess the cost-effectiveness of axi-cel compared to salvage chemotherapy using a decision model and a US payer perspective.Materials and methods: A decision model was developed to estimate life years (LYs), quality-adjusted life years (QALYs), and lifetime cost for adult patients with R/R LBCL treated with axi-cel vs salvage chemotherapy (R-DHAP). Patient-level analyses of the ZUMA-1 and SCHOLAR-1 studies were used to inform the model and to estimate the proportion achieving long-term survival. Drug and procedure costs were derived from US average sales prices and Medicare reimbursement schedules. Future healthcare costs in long-term remission was derived from per capita Medicare spending. Utility values were derived from patient-level data from ZUMA-1 and external literature. One-way and probabilistic sensitivity analyses evaluated uncertainty. Outcomes were calculated over a lifetime horizon and were discounted at 3% per year.Results: In the base case, LYs, QALYs, and lifetime costs were 9.5, 7.7, and $552,921 for axi-cel vs 2.6, 1.1, and $172,737 for salvage chemotherapy, respectively. The axi-cel cost per QALY gained was $58,146. Cost-effectiveness was most sensitive to the fraction achieving long-term remission, discount rate, and axi-cel price. The likelihood that axi-cel is cost-effective was 95% at a willingness to pay of $100,000 per QALY.Conclusion: Axi-cel is a potentially cost-effective alternative to salvage chemotherapy for adults with R/R LBCL. Long-term follow-up is necessary to reduce uncertainties about health outcomes.

An economic case for a vaccine to prevent group A streptococcus skin infections

BackgroundGroup A streptococcus (GAS) causes an exceptionally diverse range of diseases, raising questions about the optimal product characteristics of a commercially viable vaccine. The objectives of this study were to (1) estimate the current health and economic burdens caused by 24 diseases attributable to GAS each year in Australia and (2) use these estimates to explore the value of a GAS vaccine for different clinical indications, age schedules, and population groups. MethodsFor objective 1, we estimated the population heath and economic burdens by synthesising data from administrative databases, nationally representative surveys, literature reviews, public reimbursement schedules, and expert opinion. For objective 2, we modelled the prospective lifetime burden of GAS for all infants from birth, for children from 5 years of age, and for adults from 65 years of age. A vaccine was assumed to reduce each GAS disease by 70% for a period of 10 years, and the difference in outcomes between vaccinated and non-vaccinated cohorts were used to calculate the cost-effective value of vaccination. ResultsThe annual health and economic burdens of GAS diseases totalled 23,528 disability-adjusted life years and AU$185.1 million in healthcare costs respectively; approximately half of each measure was due to cellulitis, followed by other skin infections and throat infections. Reducing the incidence of throat infections, skin infections, and cellulitis in non-Indigenous cohorts resulted in 30%, 33%, and 28% of the total vaccine value for an infant schedule (cost-effective vaccine price AU$260 per course); 47%, 26%, and 22% of the value for a child schedule (AU$289); and 2%, 15% and 74% for an adult schedule (AU$489). ConclusionsA vaccine that prevents GAS cellulitis and other skin infections, in addition to throat infections, would maximise its value and commercial viability, with a cost-effective price in line with other recently-licensed and funded vaccines in Australia.

PHS148 - Readiness of Community Oncology and Urology Practices for Value-Based Care

The Centers for Medicare and Medicaid Services (CMS) have published guidelines that reward healthcare providers based on the quality of care instead of quantity. The Medicare Access and CHIP Reauthorization Act (MACRA) focuses on quality, value and accountability in determining reimbursement schedules for various services provided. The goal of this study was to evaluate the understanding and preparedness of community oncologists and urologists to implement changes in their practices to be compliant with the new CMS requirements. Quantitative market research data on various topics were collected from U.S.-based community oncology and urology treatment sites representing >800 physicians at a live event held in June 2017 using audience response system. Most physicians were from large practices and over 70% had basic knowledge about MACRA. Less than half of the representing practices were participating in a qualifying alternative payment model and only 23% were participating in the Oncology Care Model (OCM). Although 60% of the physicians felt that their practices were somewhat prepared for the Merit-based Incentive Payment System (MIPS), practices were facing significant barriers to its success including lack of qualified staff, lack of knowledge regarding MIPS requirements, and cultural shift within the practice. Half of the practices had chosen the specific quality and Advancing Care Information measures to be submitted for 2017 with respect to MIPS. Both MACRA and OCM require practice transformation to deliver value-based care. However, only 21% of the representing practices had implemented practice transformation to drive quality and savings. Overall, half of the practices would implement practice transformation to reduce hospitalizations and emergency room visits as the initial step to drive cost savings. Most oncologists and urologists were aware of MACRA. While they were concerned about impact of MACRA and OCM, most practices were not yet ready to implement value-based care.

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Paper #9 - Patient Perceptions of Surgeon Reimbursement for Rotator Cuff Repair

Background Previous studies in the arthroplasty, spine, and shoulder and elbow literature have shown that patients perceive Medicare reimbursement to surgeons to be much higher than current reimbursement schedules. Purpose To evaluate patient perceptions of surgeon reimbursement for various rotator cuff repair (RCR) procedures. Study Design Cross-sectional study. Methods We surveyed 153 patients who presented to a single surgeon's orthopaedic sports medicine clinic between October 2016 and March 2017. Patients with a new complaint of hip or knee pain, those with a new complaint of shoulder pain, or those who had undergone shoulder surgery 1 year or more prior to their current visit were included. Patients were asked how much they thought surgeons should be reimbursed for RCR procedures, including arthroscopic repair of a simple tear and a massive tear as well as open repair of an acute tear and a chronic tear. They were also asked to estimate how much they thought surgeons were reimbursed by Medicare for these procedures. They were then given actual Medicare reimbursement rates for these procedures and asked whether they believed surgeons should be reimbursed that amount. Results For arthroscopic repair of a rotator cuff tear, patients believed that surgeons should receive a mean (±SEM) reimbursement of US$5645 ± $442. This was significantly more than their estimate of what surgeons were actually reimbursed by Medicare ($3644 ± $408; P = .001). Patients also believed that surgeons should be reimbursed more than their estimate of what surgeons were actually reimbursed for arthroscopic repair of a massive tear ($8066 ± $708 vs $4694 ± $476; P = .0001), open repair of an acute tear ($8428 ± $768 vs $4549 ± $396; P = .00001), and open repair of a chronic tear ($8902 ± $844 vs $4639 ± $438; P = .00001). Both types of patient perceptions were higher than the actual state Medicare reimbursement data for all procedures surveyed (P < .001). Conclusion Consistent with previous literature, patients perceive Medicare reimbursement for RCR to be higher than what surgeons are actually reimbursed. As the United States health care system enters a bundled care environment, price transparency is increasingly important. This study indicates a need for patient education on how their health care costs are allocated.

The Cost-Effectiveness of Surgical Fixation of Distal Radial Fractures: A Computer Model-Based Evaluation of Three Operative Modalities.

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value: closed reduction and percutaneous pinning, open reduction and internal fixation, or external fixation. We developed a Markov model that projected short-term and long-term health benefits and costs in patients undergoing a surgical procedure for a distal radial fracture. Simulations began at the patient age of 50 years and were run over the patient's lifetime. The analysis was conducted from health-care payer and societal perspectives. We estimated transition probabilities and quality-of-life values from the literature and determined costs from Medicare reimbursement schedules in 2016 U.S. dollars. Suboptimal postoperative outcomes were determined by rates of reduction loss (4% for closed reduction and percutaneous pinning, 1% for open reduction and internal fixation, and 11% for external fixation) and rates of orthopaedic complications. Procedural costs were $7,638 for closed reduction and percutaneous pinning, $10,170 for open reduction and internal fixation, and $9,886 for external fixation. Outputs were total costs and quality-adjusted life-years (QALYs), discounted at 3% per year. We considered willingness-to-pay thresholds of $50,000 and $100,000. We conducted deterministic and probabilistic sensitivity analyses to evaluate the impact of data uncertainty. From the health-care payer perspective, closed reduction and percutaneous pinning dominated (i.e., produced greater QALYs at lower costs than) open reduction and internal fixation and dominated external fixation. From the societal perspective, the incremental cost-effectiveness ratio for closed reduction and percutaneous pinning compared with open reduction and internal fixation was $21,058 per QALY and external fixation was dominated. In probabilistic sensitivity analysis, open reduction and internal fixation was cost-effective roughly 50% of the time compared with roughly 45% for closed reduction and percutaneous pinning. When considering data uncertainty, there is only a 5% to 10% difference in the frequency of probability combinations that find open reduction and internal fixation to be more cost-effective. The current degree of uncertainty in the data produces difficulty in distinguishing either strategy as being more cost-effective overall and thus it may be left to surgeon and patient shared decision-making. Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Advancing the Legislative Priorities of Cardiothoracic Surgeons: The Society of Thoracic Surgeons Political Action Committee

In the late 1990s, several federal government health policy decisions threatened the viability of thoracic surgery as a specialty. To respond to such decisions, active participation in political processes was given extremely high priority by the Executive Committee of The Society of Thoracic Surgeons (STS). Creation of the STS Political Action Committee (STS-PAC) in 1997 was a part of the platform of participation. The purpose of the STS-PAC is to enhance the Society's voice and stature in health care policymaking. Although the STS-PAC receives voluntary contributions from STS members, on average, only 10% of STS members contribute to the STS-PAC. For the 2015-2016 election cycle, there were 542 contributors to the STS-PAC totaling $273,000. An annual contribution of $100 from every STS member would put the STS-PAC into the top 10 for medical PACs (whereas currently it is ranked 22nd of 28 in the group of physician and dental association PACs). Despite the relatively small dollar amount the STS-PAC directs, its strategic disbursement of these dollars has yielded impressive results. For example, the STS-PAC was able to use its influence to effectively stop the Centers for Medicare and Medicaid Services from implementing a potentially calamitous rule that would effectively end traditional global surgical payments. Other advocacy successes include providing guidance to the Centers for Medicare and Medicaid Services in developing the national coverage determination for transcatheter aortic valve replacement and structuring its complex reimbursement schedule, and ensuring that a provision was included in the bill that would give the STS National Database access to claims data. The STS-PAC is a principal component of the STS' advocacy armamentarium. Despite the many successes of the STS-PAC, with even modest contributions by more STS members, the STS-PAC could become a leading medical PAC, and would give the STS an even stronger presence and voice in Washington, DC. Clearly, contributing to the STS-PAC provides STS members the opportunity to have a voice and an impact on health policy and the care of their patients.

Cost-effectiveness of Paclitaxel + Ramucirumab Combination Therapy for Advanced Gastric Cancer Progressing After First-line Chemotherapy in Japan

PurposeThe combination of paclitaxel + ramucirumab is a standard second-line treatment in patients with advanced gastric cancer. This therapy has been associated with increased median overall survival and progression-free survival compared with those with paclitaxel monotherapy. We evaluated the cost-effectiveness of paclitaxel + ramucirumab combination therapy in patients with advanced gastric cancer, from the perspective of health care payers in Japan. MethodsWe constructed a Markov model to compare, over a time horizon of 3 years, the costs and effectiveness of the combination of paclitaxel + ramucirumab and paclitaxel alone as second-line therapies for advanced gastric cancer in Japan. Health outcomes were measured in life-years (LYs) and quality-adjusted (QA) LYs gained. Costs were calculated using year-2016 Japanese yen (¥1 = US $17.79) according to the social insurance reimbursement schedule and drug tariff of the fee-for-service system in Japan. Model robustness was addressed through 1-way and probabilistic sensitivity analyses. The costs and QALYs were discounted at a rate of 2% per year. The willingness-to-pay threshold was set at the World Health Organization's criterion of ¥12 million, because no consensus exists regarding the threshold for acceptable cost per QALY ratios in Japan's health policy. FindingsPaclitaxel + ramucirumab combination therapy was estimated to provide an additional 0.09 QALYs (0.10 LYs) at a cost of ¥3,870,077, resulting in an incremental cost-effectiveness ratio of ¥43,010,248/QALY. The incremental cost-effectiveness ratio for the combination therapy was >¥12 million/QALY in all of the 1-way and probabilistic sensitivity analyses. ImplicationsAdding ramucirumab to a regimen of paclitaxel in the second-line treatment of advanced gastric cancer is expected to provide a minimal incremental benefit at a high incremental cost per QALY. Based on our findings, adjustments in the price of ramucirumab, as well as improves in other clinical parameters such as survival time and adverse event in advanced gastric cancer therapy, are needed.

NSQIP® Indexed Complications Following Transurethral Bladder Tumor Resection and Contemporary Financial Implications

IntroductionWe determined the incidence of NSQIP (National Surgical Quality Improvement Project) indexed complications by tumor size and investigated the related financial implications based on contemporary reimbursement schedules. MethodsTransurethral bladder tumor resection procedures performed from 2010 to 2012 were identified and stratified by size specific CPT coding. Preoperative characteristics, surgical parameters and 30-day perioperative outcomes were compared using chi-square analysis and Student’s t-test. Financial data for all inpatient transurethral bladder tumor resections performed during the most recent fiscal year at our institution were collected and analyzed, and a comparison was made using up-to-date Medicare reimbursement schedules. ResultsWe identified 8,116 cases, including 3,533 coded as small (43.3%), 2,734 medium (33.5%) and 1,849 large (22.6%). Large resections required longer operative time (small—25.8 minutes, medium—33.0 minutes, large—49.0 minutes, p <0.01) and length of stay (small—0.67 days, medium—1.1 days, large—1.9 days, p <0.006), and had higher rates of transfusion (small—0.74%, medium—1.5%, large—3.7%, p <0.001), sepsis (small—0.23%, medium—0.44%, large—0.92%, p <0.05), renal insufficiency (small—0.17%, medium—0.15%, large—0.60%, p <0.01) and 30-day mortality (small—0.2%, medium—1%, large—1.8%, p <0.05) independent of preoperative parameters. Large resections were also associated with higher rates of 30-day readmission (small—4.3%, medium—6.3%, large—9.4%, p <0.001) and reoperation (small—2.1%, medium—2.7%, large—4.5%, p <0.001). Institutional data demonstrate that the most common Diagnosis Related Group classification results in an operating loss when treating Medicare beneficiaries. ConclusionsUrologist selected coding directly correlates with NSQIP indexed postoperative complications. Many cases of transurethral bladder tumor resection with associated complications may result in financial loss for the performing institutions. Efforts to improve quality of care and reimbursement seem warranted.