Surgery Reimbursement Research Articles

Changes in Medicare Reimbursement for Top Burn Surgery Procedures by State Between 2011 and 2022.

This study analyzed the geographic variation in annual Medicare reimbursement changes for common burn surgery procedures from 2011 to 2022 to clarify trends in reimbursement. The Center for Medicare and Medicaid Services' Physician fee schedule database was analyzed to find state-by-state reimbursement rates for the most common burn surgery procedures. Physician reimbursement was adjusted for inflation utilizing the consumer price index. Procedures were weighted according to frequency, and an inflation-adjusted percent change was identified for each state. Since 2011, the inflation-adjusted Medicare reimbursement for the top burn surgery procedures for all U.S. states decreased by a yearly average of 2.67%. Washington (-2.17%), New York (-2.31%), Oregon (-2.33%), and the District of Columbia (-2.35%) showed the smallest annual percent change. Illinois (-3.34%), Mississippi (-3.04%), Idaho (-2.99%), and Michigan (-2.96%) were the states with the greatest annual decrease. The most common procedures included initial treatment of burns (16000), burn dressing and debridement (16020, 16025, 16030), and burn eschar incision (16035). Medicare reimbursement for burn surgery procedures decreased from 2011 to 2022. The geographic variance in reimbursement patterns may incentivize physicians to pursue other surgical specialties or practice in certain areas which could limit access to care in low reimbursement areas. Further research is needed to examine disparities that may have arisen due to decreasing reimbursement over the last decade. New action is also needed to moderate diminishing burn surgery reimbursement to ensure quality care for Medicare beneficiaries in low-reimbursement states.

A Nationwide Analysis of Complications, Reoperations and Cost of Wide-Awake Flexor Tendon Repairs.

Some papers suggest that wide-awake flexor tendon repair (FTR) may reduce rates of postoperative tendon gapping and rupture due to improved intraoperative testing of the repair. The current study is a nationwide cohort study comparing FTRs performed wide-awake and with traditional anesthesia. Patients undergoing zone II FTR between 2010-2022 were identified in PearlDiver. Exclusion criteria were other tendon repairs, concomitant treatment for vascular injury, fracture, dislocation or amputation, inpatient or office surgery, age <18 years and <1 year of follow-up. Patients were stratified by anesthesia technique: traditional anesthesia (general anesthesia, monitored anesthesia care, regional blocks) or wide-awake. Patients were matched based on age, sex, Elixhauser Comorbidity Index (ECI) score, geographical region, insurance coverage, number of tendon repairs and presence of concomitant nerve repair. 30-day wound complications, emergency department visits and readmissions and 1-year reoperations were identified. Total reimbursement for surgery was determined. Each matched cohort included 2,563 patients. Wide-awake patients had fewer 30-day emergency department visits (2.7% vs 4.8%). There were no differences in 30-day wound complications or readmissions. There was no difference in 1-year reoperations for rupture or for stiffness. Multivariable linear regression identified wide-awake surgery to be a significantly associated with lower total reimbursement. Performing digital FTR using wide-awake techniques can reduce costs, but the hypothesis that wide-awake repairs may reduce rates of tendon rupture was not supported by the current study.

A retrospective study of orthognathic surgery reimbursement and volume changes at an American academic medical center over a 13-year period

This study aimed to measure the association between orthognathic surgeon reimbursement and surgical volume over time. A retrospective cohort study of patients who underwent orthognathic surgery from January 1, 2010, to December 23, 2022, at an academic medical center was performed. Five patients per year were randomly selected and evaluated for insurance type and associated costs to create representative averages. Pearson correlation analysis was performed to test associations over 13 years with 2-tailed significance reported and statistical significance set at P < .05. A total of 618 patients who underwent 942 procedures were included. The average procedure charge was $6,153.76, and the average total surgeon collection was $1,535.75 per procedure. When monetary values were adjusted to reflect 2010 purchasing power, there was a negative correlation between the average charge per procedure and the year (r[11] = -0.59, P = .04). The year was not significantly correlated with the average amount collected (r[11] = -0.09, P = .78) or average insurance reimbursement (r[11] = -0.52, P = .07). Collections by surgeons did not change significantly over 13 years and were not correlated with the volume of procedures performed. Increased collections were correlated with increased patient costs. The stagnation of surgeon collection is concerning in the face of increased monetary inflation during this period. Increased volume of surgeries per year was correlated with decreases in patient cost and total collections.

Association of Frailty with Healthcare Utilization for Patients over One Year Following Surgical Evaluation.

Characterize the distribution of healthcare utilization associated with pre-operative frailty in the year following evaluation by a surgeon. Frailty is associated with increased morbidity, mortality, and costs for surgical patients. However, the total financial burden for frail patients beyond the index surgery and inpatient stay remains unknown. Prospective cohort assembled from February 2016 to December 2020 within a multi-hospital integrated healthcare delivery and finance system (IDFS), from patients evaluated with the Risk Analysis Index (RAI) of frailty. Inclusion criteria: age greater than 18, valid RAI, membership in the IDFS Health Plan. Data were stratified by frailty and surgical status. The mean (SD) age was 54.7 (16.1) and 58.2% female of the cohort (n=86,572). For all patients with reimbursement for surgery (n=53,856), frail and very frail patients incurred respective increases of 8% ( P =0.027) and 29% ( P <0.001) on utilization relative to the normal group. Robust patients saw a 52% ( P <0.001) decrease. This pattern was more pronounced in the cohort without surgery (n=32,716). The increase over normal utilization for frail and very frail patients increased to 23% ( P =0.004) and 68% ( P <0.001), respectively. Utilization among robust patients decreased 62% ( P <0.001). Increases among the frail were primarily due to increased inpatient medical and post-acute care services (all P <0.001). Patient frailty is associated with increased total healthcare utilization, primarily via increased inpatient medical and post-acute care following surgery. Quantifying these frailty-related financial burdens may inform clinical decision making as well as the design of value-based reimbursement strategies.

Analysis of Medicaid and Medicare Reimbursement Variations for Common Orthopaedic Trauma Procedures

OBJECTIVES: Medicaid (MCD) reimbursement for surgery is determined by state governments and is subject to substantial variation in comparison to Medicare (MCR), which is determined by the federal government and invariable across the United States. This mismatch in reimbursement has previously been described as a component of the disparity in access to care in orthopaedics. While this variation has been previously quantified for general orthopaedics and orthopaedic hand surgery, no such analysis has been performed for orthopaedic trauma. This study aims to quantify the variation in MCD and MCR reimbursement for common orthopaedic trauma procedures.&#x0D; DESIGN: Billing data obtained from a Level I trauma center were retrospectively reviewed and the ten most commonly billed Current Procedural Terminology (CPT) codes were extracted. State and federal physician fee schedules were collected and assessed to determine MCD- and MCR-specific reimbursement rates, or relative value units (RVUs), for these ten procedures. An economic analysis was then conducted to evaluate the disparities between MCD and MCR reimbursement.&#x0D; MAIN OUTCOME MEASURES: MCD and MCR RVUs for each procedure were compared using dollar difference and coefficient of variation (CV).&#x0D; RESULTS: Our analysis showed considerable variance in MCD reimbursement rates between states. Additionally, we found that the majority of RVUs for MCD were higher than MCR for the evaluated trauma procedures.&#x0D; CONCLUSION: The variance in MCD reimbursement values may be driven by differences in the underlying characteristics of each systems’ patient population. This variance, particularly in bordering states, could represent a barrier to healthcare access for some populations.

Do Changes in Orthognathic Surgery Reimbursement Affect the Volume of Procedures Performed at an Academic Medical Center?

Do Changes in Orthognathic Surgery Reimbursement Affect the Volume of Procedures Performed at an Academic Medical Center?

Ocular Involvement and Treatment Pattern in Korean Patients with Marfan Syndrome: A Population-Based Study

ABSTRACT Purpose This study aimed to investigate the incidence and prevalence of, and treatment patterns for ocular complications in Korean patients with Marfan syndrome Methods Incidence and prevalence of Marfan syndrome was calculated from 2010 to 2018, based on data from the Korean National Health Insurance Service (KNHIS). Diagnosis codes (for cataract, ectopia lentis, retinal detachment, etc.) and surgery reimbursement codes (lensectomy, phacoemulsification, buckling, vitrectomy, etc.) in the patients with Marfan syndrome were retrieved by complete enumeration of the data. Results The annual prevalence of Marfan syndrome adjusted by age and sex was gradually increased from 2.44 per 100,000 in 2010 to 4.36 per 100,000 in 2018. The age group of 10–19 years showed the highest prevalence. The prevalence of ectopia lentis was 21.7%, of whom 43.0% underwent surgeries. Surgery for RD was performed in 253 (14.1%) of 2044 patients during the study period. Conclusion Although the most prevalent ophthalmologic manifestation was ectopia lentis, total prevalence rate of RD was more than 10% in the study period; thus, regular fundus examination is recommended for the patients with Marfan syndrome.

Comparison of Incremental Costs and Medicare Reimbursement for Simple vs Complex Cataract Surgery Using Time-Driven Activity-Based Costing

Cataract surgery is one of the most commonly performed surgeries across medicine and an integral part of ophthalmologic care. Complex cataract surgery requires more time and resources than simple cataract surgery, yet it remains unclear whether the incremental reimbursement for complex cataract surgery, compared with simple cataract surgery, offsets the increased costs. To measure the difference in day-of-surgery costs and net earnings between simple and complex cataract surgery. This study is an economic analysis at a single academic institution using time-driven activity-based costing methodology to determine the operative-day costs of simple and complex cataract surgery. Process flow mapping was used to define the operative episode limited to the day of surgery. Simple and complex cataract surgery cases (Current Procedural Terminology codes 66984 and 66982, respectively) at the University of Michigan Kellogg Eye Center from 2017 to 2021 were included in the analysis. Time estimates were obtained using an internal anesthesia record system. Financial estimates were obtained using a mix of internal sources and prior literature. Supply costs were obtained from the electronic health record. Difference in day-of-surgery costs and net earnings. A total of 16 092 cataract surgeries were included, 13 904 simple and 2188 complex. Time-based day-of-surgery costs for simple and complex cataract surgery were $1486.24 and $2205.83, respectively, with a mean difference of $719.59 (95% CI, $684.09-$755.09; P < .001). Complex cataract surgery required $158.26 more for costs of supplies and materials (95% CI, $117.00-$199.60; P < .001). The total difference in day-of-surgery costs between complex and simple cataract surgery was $877.85. Incremental reimbursement for complex cataract surgery was $231.01; therefore, complex cataract surgery had a negative earnings difference of $646.84 compared with simple cataract surgery. This economic analysis suggests that the incremental reimbursement for complex cataract surgery undervalues the resource costs required for the procedure, failing to cover increased costs and accounting for less than 2 minutes of increased operating time. These findings may affect ophthalmologist practice patterns and access to care for certain patients, which may ultimately justify increasing cataract surgery reimbursement.

Trends in Metabolic and Bariatric Surgery Reimbursement in the USA.

Trends in Metabolic and Bariatric Surgery Reimbursement in the USA.

Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021.

Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021. The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (-38.7%), while the smallest mean decrease was in vertebral body excision (-17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69. This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

Physician Reimbursement for Vascular Surgery Procedures and Vascular Laboratory Studies Before and After the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA), fully implemented by 2015, has significantly increased the number of Americans with health insurance. However, its impact on physician reimbursement (PR) is not well studied. Our objective was to determine the ACA's impact on the professional component of PR for selected vascular surgery (VS) procedures and vascular laboratory (VL) studies at our institution. PR for the following 5 VS procedures and 4 VL studies were obtained from our billing department: CPT 34803 (Endovascular aortic repair, EVAR), 35301 (carotid endarterectomy, CEA), 35656 (lower extremity bypass, LEB), 36010 (introduction of catheter into vena cava, ICVC), 36200 first, 93922 (ankle brachial index, ABI), 93925 (lower extremity arterial duplex, LEA duplex), 93970 (lower extremity venous duplex, LEV Duplex), and 93990 (hemodialysis duplex). The data was organized by payer: Medicare, Medicaid, Commercial Insurers (CI), and Other. PR was studied pre-ACA (January 2008 through December 2009) and post-ACA (January 2015 through December 2016). The post-ACA PR and inflation adjusted reimbursement (IAR) in 2016 dollars using the consumer price index (CPI) were calculated and compared using one-sample t-test. The percent difference between the post-ACA PR and IAR was also compared. PR for 1,637 VS procedures and 16,333 VL studies was analyzed. The post-ACA PR was significantly lower than the IAR for most Medicare and Medicaid procedures. For EVAR, post-ACA reimbursement was overall on par with the IAR but significantly lower for Medicare. For CEA, post-ACA reimbursement was overall lower than IAR. For LEB, overall average PR was lower than IAR, with statistically significant lower Medicare and Medicaid (P < 0.001) payments. For ICAo, overall PR was significantly lower than the IAR and this was true across all insurance types. In contrast, for ICV, the post-ACA reimbursement was higher than IAR for all payers but did not reach statistical significance (P=0.25). The post-ACA PR was significantly higher than the IAR for most VL studies, except for Medicare PR. The percent change for VS procedures were mostly negative for the Medicaid and Medicare groups. This results in potential annual shortcomings of $2, 862 and $20,923 respectively. When comparing reimbursement before and after ACA implementation, Medicare and Medicaid PR for most VS procedures has not kept up with inflation. However, for most VL procedures, PR has exceeded inflation. Further efforts are needed to support Vascular Surgery reimbursement including higher valuation of the Medicare Conversion factor.

Strategies for spinal surgery reimbursement: bundling in the working-age population

IntroductionBundled payments for spine surgery, which is known for having high overall cost with wide variation, have been previously studied in older adults. However, there has been limited work examining bundled payments in working-age patients. We sought to identify the variation in the cost of spine surgery among working age adults in a large, national insurance claims database.MethodsWe queried the TRICARE claims database for all patients, aged 18–64, undergoing cervical and non-cervical spinal fusion surgery between 2012 and 2014. We calculated the case mix adjusted, price standardized payments for all aspects of care during the 60-, 90-, and 180-day periods post operation. Variation was assessed by stratifying Hospital Referral Regions into quintiles.ResultsAfter adjusting for case mix, there was significant variation in the cost of both cervical ($10,538.23, 60% of first quintile) and non-cervical ($20,155.59, 74%). Relative variation in total cost decreased from 60- to 180-days (63 to 55% and 76 to 69%). Index hospitalization was the primary driver of costs and variation for both cervical (1st-to-5th quintile range: $11,033–$19,960) and non-cervical ($18,565–$36,844) followed by readmissions for cervical ($0–$11,521) and non-cervical ($0–$13,932). Even at the highest quintile, post-acute care remained the lowest contribution to overall cost ($2070 & $2984).ConclusionsThere is wide variation in the cost of spine surgery across the United States for working age adults, driven largely by index procedure and readmissions costs. Our findings suggest that implementing episodes longer than the current 90-day standard would do little to better control cost variation.

Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system

IntroductionMagnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective.Methods and proceduresThis prospective observational study was performed in conjunction with the region’s largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members’ claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups.ResultsThere were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195–14,439) for those who underwent MSA and $13,388 (9951–16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10).ConclusionWhen compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.

Cost-utility analysis of cervical deformity surgeries using 1-year outcome

Background ContextCost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction. Study DesignThis is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2–C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2–C7 sagittal vertical axis >4 cm or T1–C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4–8 level PF, 4–8 level PF with anterior fusion (AF), 2–3 level PF with AF, 4–8 level AF, and 4–8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility. ResultsEighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4–8 level PF ($40,596), 4–8 level PF with AF ($67,098), 4–8 level AF ($31,392), and 4–8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3–4.5 years after intervention. ConclusionsMedicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3–4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction.

Operational cost of obesity surgery in Turkey

Introduction: Obesity and its comorbidities are among the primary challenges health systems face globally. Obesity is rapidly becoming a problem in Turkey, as well. The real cost of obesity surgery differs from country to country mainly due to differences in the costs of health care services, medical devices and medicines. The objective of this study is to fi nd out the operational cost of obesity surgery in Turkey. Materials and Methods: Expert panel is the main methodology used in the study. An expert panel questionnaire form was designed after the literature review aiming at fi nding the costs. The form was sent to the experts in advance and a panel discussion was undertaken to reach a consensus. After the consensus building phase, the cost of surgical treatment of obesity was estimated based on the public reimbursement and auction price. Results: Laparoscopic by-pass surgery had the highest cost compared to others, in both operational and post-op costs. The highest cost for pre-op was the laparoscopic sleeve operations. The package payment included all costs and services between pre-operative period and 15 days after operation. Based on the analysis, the package reimbursement prices were below their actual costs for all surgical methods. Conclusion: Social Security Institution reimburses the obesity surgery with a fi xed amount of 4500 TL, 3100 TL and 2250 TL for by-pass, sleeve and banding surgeries, respectively. This fi xed amount covers pre-operative, operative and post operative period. It was shown that the fi xed amount is lower than the real cost of the practice of obesity surgery. As a result, hospital managements can avoid performing obesity surgery or reduce the quality of the surgical treatment by lowering possible losses. Decision makers may need to evaluate the results of the study to understand the real picture and to take action in order to improve the obesity surgery reimbursement.

Reduction of Treatment Duration in Periprosthetic Infection with a Fast-Track Concept Is Economically Not Feasible

In the two stage revision of periprosthetic joint infection (PJI), the prosthesis-free interval may be reduced to 2-3 weeks (fast-track). This is an innovative approach with clear advantages for both the patient and health insurance stakeholders. The prosthesis-free interval with conventional two-stage PJI slow-track procedures lasts 6-12 weeks. In Germany, the patient spends this time either at home or in a geriatric hospital. This period is mainly used to manage infections. The patient is then readmitted for implantation of the revision prosthesis. This readmission then leads to additional reimbursement, as this is formally a new insurance case. Despite this double payment, the costs for the treatment of such complex diseases are not covered by the German DRG system. If hospitals are to implement the proven fast-track concept, they need to invest in a multidisciplinary medical team. This would be responsible for defining infections, selecting patients, and improving diagnosis and antimicrobial therapy and should thus improve the rates of cure of infections. However, the G-DRG reimbursement system treats the two surgeries as a single case, providing that less than 30 days lies between the two interventions; as a result, the reimbursement is inadequate for patients with the fast-track interval. We analysed the theoretical financial deficit for a hospital and describe the cost-saving potential for payers applying the fast-track interval rather than the slow-track approach in selected PJI patients, using a comprehensive and individualised treatment concept. Our analysis covered thirty-two consecutive patients with infected joint prosthesis (17 hips, 15 knee) admitted to our hospital from January 2011 to December 2012 undergoing a two-stage exchange (ICD-10-GM: T84.5). We excluded patients who underwent only one hospital admission during the analysed time frame or who were admitted to another hospital. Patients treated with joint fusion and patients who died were also excluded. A retrospective simulation of the DRG reimbursement was then performed according to the German Hospital Fees Act (§ 21 KHEntgG) for the two-stage fast-track interval concept. Due to the retrospective character, we could not analyse detailed financial differences specifically related to the fast-track treatment, such as the cost for biofilm active antimicrobial drugs and savings for outpatient care during the long interval in slow-track. We did not consider hospital investment costs for establishing an interdisciplinary medical team, and were only able to roughly describe the cost saving potential and benefits on a societal perspective. With the fast-track concept, the DRG receipts were reduced by a mean of 10 831 € per patient, which was higher for hip prostheses than for knee prostheses. Even though fast-track treatment cost 1159 € less than slow-track treatment, the hospital lost 8498 € per fast-track patient, because of the loss of the second surgery reimbursement. For each fast-track patient, the payers save one G-DRG reimbursement plus the costs for any care during the prosthesis-free interval, as occurred in the slow-track. Fast-track patients benefit from the reduced period of functional treatment, of about 10 weeks. The current G-DRG reimbursement system paradoxically rewards slow-track intervals for two-stage revisions and jeopardizes the implementation of beneficial fast-track intervals in clinical routine. Patients treated with slow-track therapy experience longer and more debilitating treatment, accompanied by greater healthcare costs for both payers and hospitals. New treatment concepts which offer better care at lower cost should attract the attention of policy makers, clinicians, and the public.

Superficial Wound Closure Complications with Barbed Sutures Following Knee Arthroplasty

As quality measures may be increasingly used in knee surgery reimbursement, an important focus in outcome assessment will shift toward minimizing complications and increasing efficiency in knee arthroplasty reconstruction. The purpose of this study was to evaluate the efficacy of barbed, absorbable sutures in closure of the longitudinal surgical incision following knee arthroplasty, using post-operative complication occurrences. In 416 operations, primary outcomes assessed were deep infection, superficial infection, dehiscence, or stitch abscesses. Secondary outcomes included self-limiting eschar, severe effusion, arthrofibrosis, and keloid formation. Evaluation of overall primary outcomes showed a higher rate of wound complications using barbed sutures (P<0.001). With increased rates of infection and overall closure related complications, this study shows that barbed suture use for superficial closure after knee arthroplasty should be avoided.

Optimizing Hospital Reimbursement Through Physician Awareness: A Step Toward Better Patient Care

We instituted a training program to improve the overall accuracy of medical record coding through greater physician awareness to enhance hospital reimbursement and maintain quality patient care. A physician-targeted course reviewed the prospective payment system, diagnosis-related group guidelines, ambulatory surgery reimbursement, and the relationship between accurate physician documentation and medical record coding. Annual increases in charges from prospective surgical case assignment, proper conversion of outpatient to inpatient status, and more accurate coding of inpatient comorbidities and complications led to an estimated increase in hospital charges of $1.6 million.

A Comparison of Intensive Care Unit Care of Surgical Patients in Teaching and Nonteaching Hospitals

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.

A Comparison of Intensive Care Unit Care of Surgical Patients in Teaching and Nonteaching Hospitals

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.