Ferguson T B, Ferguson C L, Crites K, Crimmins-Reda P
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
J Thorac Cardiovasc Surg. 1996 Apr;111(4):742-51;discussion 751-2. doi: 10.1016/s0022-5223(96)70334-3.
The rapid approach of capitated reimbursement mandates that providers examine their practice patterns associated with all surgical procedures. Documentation of (1) the complications associated with these procedures and (2) the additional hospital costs associated with the management of these complications is critical for comprehensive fiscal accountability. This study analyzed (1) the feasibility of obtaining accurate hospital cost data specific for complications and (2) the outcome in terms of fully loaded hospital costs generated in the management of the most common surgical complications associated with pacemaker and nonthoracotomy implantable defibrillator therapies. Between July 1989 and September 1994, a total of 1031 pacemaker and 105 implantable defibrillator procedures were performed by a cardiac surgeon in a tertiary-level teaching hospital setting. The additional fully loaded hospital costs were determined by (1) correlating clinical data from the complete medical record with complete hospital charge data for the admission(s) related to the complication, (2) carving out complication-related charges based on the clinical data, (3) converting complication-related charges to fully loaded costs based on conversion factors in effect at the time of service, and (4) correlating cost with hospital net reimbursement and payor source. The feasibility study determined that accurate and reliable cost data specific to complications can be obtained, although the process was cumbersome and difficult. The outcomes study determined that mean fully loaded complication costs were $4345 +/- $1540 for pacemaker lead revision and $4879 +/- $3167 for implantable defibrillator lead dislodgement, $24,459 +/- $14,585 for pacemaker infection, and $13,736 +/- $12,505 for defibrillator generator system malfunction. The one infected defibrillator cost $57,213 to treat. Costs exceeded reimbursement for almost all Medicare patients with complications in this study, suggesting that similar shortfalls would occur under a capitation scheme. This information is critical to a complete understanding of the financial impact of interventional procedures in a capitated reimbursement environment.
按人头付费报销方式的迅速推行，要求医疗服务提供者审视其与所有外科手术相关的诊疗模式。记录（1）这些手术相关的并发症，以及（2）与这些并发症管理相关的额外医院成本，对于全面的财务问责至关重要。本研究分析了（1）获取特定并发症准确医院成本数据的可行性，以及（2）在起搏器和非开胸植入式除颤器治疗相关最常见外科并发症管理中产生的完全成本核算的医院成本方面的结果。在1989年7月至1994年9月期间，一位心脏外科医生在一家三级教学医院环境中总共进行了1031例起搏器手术和105例植入式除颤器手术。额外的完全成本核算的医院成本通过以下方式确定：（1）将完整病历中的临床数据与并发症相关住院的完整医院收费数据相关联，（2）根据临床数据剔除与并发症相关的收费，（3）根据服务时有效的转换因子将与并发症相关的收费转换为完全成本，以及（4）将成本与医院净报销和付款方来源相关联。可行性研究确定，尽管过程繁琐且困难，但可以获得特定并发症准确可靠的成本数据。结果研究确定，起搏器导线修订的平均完全成本核算并发症成本为4345美元±1540美元，植入式除颤器导线脱位为4879美元±3167美元，起搏器感染为24459美元±14585美元，除颤器发生器系统故障为13736美元±12505美元。一例感染的除颤器治疗成本为57213美元。在本研究中，几乎所有有并发症的医疗保险患者的成本都超过了报销金额，这表明在按人头付费方案下也会出现类似的资金缺口。这些信息对于全面了解按人头付费报销环境中干预性手术的财务影响至关重要。
