Schoenfeld Andrew J, Harris Mitchel B, Liu Haiyin, Birkmeyer John D
Robert Wood Johnson Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI 48109, USA.
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
Spine J. 2014 Dec 1;14(12):2793-8. doi: 10.1016/j.spinee.2014.07.002. Epub 2014 Jul 11.
Although the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals.
To examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals.
All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included.
Included 185,954 episodes of spine surgery performed between 2005 and 2007.
Payments per episode of spine surgery.
All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment.
Episode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses.
Medicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care.
尽管脊柱手术费用高昂已得到普遍认可，但关于不同医院收费差异程度的信息却很少。
研究全国医疗保险人群脊柱手术单次费用的差异情况。我们还试图确定高费用医院费用差异的根本原因。
纳入2005年至2007年间全国按服务收费的医疗保险人群中因三种病症（椎管狭窄、椎体滑脱和腰椎间盘突出症）接受手术的所有患者。
包括2005年至2007年间进行的185,954例脊柱手术。
脊柱手术单次费用。
确定2005年至2007年间全国按服务收费的医疗保险人群中因三种病症（椎管狭窄、椎体滑脱和腰椎间盘突出症）接受手术的所有患者（185,954例脊柱手术）。医院按费用由低到高排名，并分为五等份。结果采用经验贝叶斯方法进行风险和价格调整。然后，我们评估了首次住院、医生服务、再入院和急性后期护理对总体费用差异的贡献。
最高五分之一组医院的单次费用是最低五分之一组医院的两倍多（34,171美元对15,997美元）。经过风险和价格调整后，最高五分之一组医院的总单次费用仍高出9,210美元（47%）。手术选择，包括融合手术的使用，是总单次费用的主要决定因素。然而，在调整手术选择后，最高五分之一组医院的费用仍比最低组医院高出28%。急性后期护理使用的差异占医院间费用剩余差异的大部分。对椎间盘突出症、椎管狭窄和椎体滑脱进行亚组分析后，医院单次费用的差异程度相似。还发现，对一种病症收费高的医院对其他脊柱疾病提供的服务收费也高。
医疗保险对脊柱手术单次费用的支付在不同医院间差异很大。在应对医疗改革中固有的新财务激励措施时，高费用医院应关注脊柱融合手术和急性后期护理的使用。
