Department of Surgery, University of Michigan, Ann Arbor, MI.
Stephen M. Ross School of Business, University of Michigan, Ann Arbor, MI.
Ann Surg. 2018 Dec;268(6):1014-1018. doi: 10.1097/SLA.0000000000002462.
To describe hospital-level variation in roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in Michigan.
Bariatric surgery is an increasingly prevalent elective surgical procedure that will likely be considered for future bundled payment programs, both public and private. Past research in the Medicare population found that the index hospitalization is responsible for the majority of payment variation among hospitals. However, this research largely excluded SG, now the most commonly performed bariatric surgery procedure nationally.
We used data from a state-wide quality collaborative to calculate the average risk and price-adjusted 30-day episode payment for patients undergoing RYGB and SG procedures at Michigan hospitals between January 2009 and October 2014. We organized hospitals into quintiles and compared the variation in payments between highest and lowest-cost quintiles, and also the payment categories that drove this variation.
We identified 9035 patients undergoing RYGB (n = 4194) or SG (n = 4841) procedures at 31 hospitals. The average price and risk-adjusted episode payment ranged from $11,874 in the lowest hospital quintile to $13,394 in the highest quintile, representing a difference of $1519 (12.8%). Payments for the index hospitalization accounted for the largest share of total episode costs for both procedure types. Despite representing 2.7% to 6.0% of payments across quintiles, postdischarge payments explained 22.6% of hospital variation in SG. Similarly, readmissions explained 24.5% of payment variation for SG episodes, despite representing between 1.2% and 4.4% of payments.
Collectively, our findings suggest that there are previously underappreciated differences in episode payment variation between bariatric surgery procedures. SG may be more amenable to cost containment under bundled payment initiatives by virtue of the greater share of variation explained by readmission and postdischarge payments, components of episode payment more likely to be influenced by provider discretion.
描述密歇根州医院级别罗伊氏胃旁路术（RYGB）和袖状胃切除术（SG）的差异。
减重手术是一种日益流行的择期手术，无论是公共的还是私人的，都可能被考虑用于未来的捆绑支付计划。过去在医疗保险人群中的研究发现，索引住院治疗是医院间支付差异的主要原因。然而，这项研究在很大程度上排除了 SG，它现在是全国最常见的减肥手术。
我们使用全州范围内的质量合作数据，计算了 2009 年 1 月至 2014 年 10 月期间在密歇根州医院接受 RYGB 和 SG 手术的患者的平均风险和价格调整后 30 天的病例支付。我们将医院分为五分位数，并比较了最高和最低成本五分位数之间的支付差异，以及导致这种差异的支付类别。
我们确定了 31 家医院的 9035 名接受 RYGB（n=4194）或 SG（n=4841）手术的患者。平均价格和风险调整后的病例支付从最低五分位数的 11874 美元到最高五分位数的 13394 美元不等，相差 1519 美元（12.8%）。索引住院治疗的支付占两种手术类型的总病例成本的最大份额。尽管在五分位数中占支付的 2.7%至 6.0%，但出院后支付解释了 SG 病例中 22.6%的医院差异。同样，尽管在支付中占 1.2%至 4.4%，但 SG 病例的再入院解释了支付变化的 24.5%。
总的来说，我们的研究结果表明，减肥手术之间的病例支付差异存在以前被低估的差异。由于再入院和出院后支付解释了更多的变化，SG 可能更适合捆绑支付计划下的成本控制，而这些支付是病例支付的组成部分，更有可能受到提供者自由裁量权的影响。
