DRG, costs and reimbursement following Roux-en-Y gastric bypass: an economic appraisal.

BACKGROUND

There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public.

METHODS

133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Student's t-test and standard deviation.

RESULTS

The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance (931 US dollars +/-73 vs 2356 US dollars +/-822, P<0.001). Likewise, there was a large difference in hospital reimbursement (public 11773 US dollars +/- 4462 vs private 4435 US dollars +/- 3106, P<0.001). The estimated costs for open gastric bypass was 3179 US dollars vs 4180 US dollars for the laparoscopic bypass. The HMO per diem rate was 1000 US dollars per day.

CONCLUSION

There is a relative disincentive for surgeons to treat publicly-insured patients, while there is an incentive for hospitals to treat those patients. The converse is true for the privately-insured patients. This dichotomy will impede the development of new centers and place greater burden on bariatric surgeons to reduce cost by performing the open RYGBP.