Dimick Justin B, Weeks William B, Karia Raj J, Das Smita, Campbell Darrell A
VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
J Am Coll Surg. 2006 Jun;202(6):933-7. doi: 10.1016/j.jamcollsurg.2006.02.015.
Both providers and payors bear the financial risk associated with complications of poor quality care. But the stakeholder who bears the largest burden of this risk has a strong incentive to support quality improvement activities. The goal of the present study was to determine whether hospitals or payors incur a larger burden of increased hospital costs associated with complications.
We merged clinical data for 1,008 surgical patients from the private sector National Surgical Quality Improvement Program to the internal cost-accounting database of a large university hospital. We then determined the marginal costs of surgical complications from the perspective of both hospitals (changes in profit and profit margin) and payors (increase in reimbursement paid to the hospital). In our analyses of cost and reimbursement, we adjusted for procedure complexity and patient characteristics using multivariate linear regression.
Reimbursement for patients without complications ($14,266) exceeded hospital costs ($10,978), generating an average hospital profit of $3,288 and a profit margin of 23%. When complications occurred, hospitals still received reimbursement in excess of their costs, but the profit margin declined: reimbursement ($21,911) exceeded hospital costs ($21,156), yielding an average profit of $755 and a profit margin of 3.4%. Complications were always associated with an increase in costs to health-care payors: complications were associated with an average increase in reimbursement of $7,645 (54%) per patient.
Hospitals and payors both suffer financial consequences from poor-quality health care, but the greater burden falls on health-care payors. Strong incentives exist for health-care payors to become more involved in supporting quality improvement activities.
医疗服务提供者和支付方都承担着与低质量医疗并发症相关的财务风险。但承担这种风险最大负担的利益相关者有强烈的动机支持质量改进活动。本研究的目的是确定医院或支付方是否承担与并发症相关的医院成本增加的更大负担。
我们将来自私营部门国家外科质量改进计划的1008例外科手术患者的临床数据与一家大型大学医院的内部成本核算数据库进行了合并。然后，我们从医院（利润和利润率的变化）和支付方（支付给医院的报销增加）的角度确定了手术并发症的边际成本。在我们对成本和报销的分析中，我们使用多元线性回归对手术复杂性和患者特征进行了调整。
无并发症患者的报销费用（14266美元）超过了医院成本（10978美元），医院平均利润为3288美元，利润率为23%。当出现并发症时，医院仍获得超过其成本的报销，但利润率下降：报销费用（21911美元）超过医院成本（21156美元），平均利润为755美元，利润率为3.4%。并发症总是与医疗保健支付方的成本增加相关：并发症与每位患者平均7645美元（54%）的报销增加相关。
医院和支付方都因低质量医疗保健而遭受财务后果，但更大的负担落在医疗保健支付方身上。医疗保健支付方有强烈的动机更多地参与支持质量改进活动。
