What Is the Value of Undergoing Surgery for Spinal Metastases at Dedicated Cancer Centers?

BACKGROUND: The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases. QUESTION/PURPOSE: Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals? METHODS: The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs. RESULTS: After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001). CONCLUSION: Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Value of Supporting Education Research in the Academic Environment: The Hospital for Special Surgery Academy of Rheumatology Medical Educators.

PROBLEM: Medical education academies have been instrumental in providing greater recognition of and promotion for clinician-educators. However, producing education scholarship is essential for clinician-scholar-educator career advancement. Grant funding for education research and protected time to produce scholarship are still lacking for interested physicians, in part due to institutional budget constraints and competing priorities. APPROACH: The Hospital for Special Surgery Academy of Rheumatology Medical Educators was founded in 2011 to promote education scholarship through grants awarded to educators interested in research. Educators were asked to submit proposals aimed at the development of new teaching programs and curricular change. Selected applicants received up to $50,000 per year for one year. Grant money was obtained through directed fundraising from donors. Information from annual grant updates and survey responses from grant recipients in 2017 were used to assess the academy's effectiveness. OUTCOMES: Since 2012, 32 grants have been awarded, totaling $954,045 in funding. Recipients have produced national meeting abstracts, posters, oral presentations, and manuscripts and created unique curricula and electronic learning tools for medical students, residents, fellows, faculty, and patients. Four educators with demonstrated interest and research outcomes were identified during the pilot and received additional funding and support from a dedicated education research assistant. NEXT STEPS: The academy and the innovations grants program highlight the talents of under-supported and under-recognized teaching faculty by allowing them to distinguish themselves academically as clinician-scholar-educators. The success of these educators emphasizes the clear advantages of a formalized structure to achieve the hospital's education goals. Next steps include providing support for a rheumatology fellow to develop an education research career rather than one in bench, clinical, or translational research.

Variation in the Cost of Care for Different Types of Joint Arthroplasty.

BACKGROUND: Lower-extremity arthroplasty constitutes the largest burden on health-care spending of any Medicare diagnosis group. Demand for upper extremity arthroplasty also continues to rise. It is necessary to better understand costs as health care shifts toward a bundled-payment accounting approach. We aimed (1) to identify whether variation exists in total cost for different types of joint arthroplasty, and, if so, (2) to determine which cost parameters drive this variation. METHODS: The cost of the episode of inpatient care for 22,215 total joint arthroplasties was calculated by implementing time-driven activity-based costing (TDABC) at a single orthopaedic specialty hospital from 2015 to 2018. Implant price, supply costs, personnel costs, and length of stay for total knee, total hip, anatomic total shoulder, reverse total shoulder, total elbow, and total ankle arthroplasty were analyzed. Individual cost parameters were compared with total cost and volume. RESULTS: Higher implant cost appeared to correlate with higher total costs and represented 53.8% of the total cost for an inpatient care cycle. Total knee arthroplasty was the least-expensive and highest-volume procedure, whereas total elbow arthroplasty had the lowest volume and highest cost (1.65 times more than that of total knee arthroplasty). Length of stay was correlated with increased personnel cost but did not have a significant effect on total cost. CONCLUSIONS: Total inpatient cost at our orthopaedic specialty hospital varied by up to a factor of 1.65 between different fields of arthroplasty. The highest-volume procedures-total knee and hip arthroplasty-were the least expensive, driven predominantly by lower implant purchase prices. CLINICAL RELEVANCE: We are not aware of any previous studies that have accurately compared cost structures across upper and lower-extremity arthroplasty with a uniform methodology. The present study, because of its uniform accounting process, provides reliable data that will allow clinicians to better understand cost relationships between different procedures.

Outcomes Following Colorectal Resection in Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population. METHODS: We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors. RESULTS: In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p < 0.001; adjusted odds ratio [aOR] 2.683.594.81) as were overall complications (38.5 vs 31.5%, p = 0.001; aOR 1.081.301.56). LOS was significantly longer (10 vs 7 days, p < 0.001; ratio 1.421.531.65) and cost was significantly greater ($23,056 vs $14,139, p < 0.001; ratio 1.421.541.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p = 0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type. CONCLUSIONS: KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

Hospitalizations for Cardiovascular Disease After Liver Transplantation in the United States.

Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.

Spending on Bariatric Surgery in the Unified Health System from 2010 to 2014: a Study Based on the Specialist Hospitals Authorized by the Ministry of Health.

BACKGROUND: The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil's public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications. METHODS: Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed. RESULTS: There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period. CONCLUSIONS: Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

Política de asignación de recursos del Seguro Popular: análisis y recomendaciones / Resource allocation in the Seguro Popular program: analysis and recommendations

Resumen: Objetivo: Describir los mecanismos de asignación y compra del Seguro Popular, la forma en que operan y los controles que se dan sobre ellos. Discutir esquemas de incentivos que mejoren el desempeño en general, fortalezcan la atención primaria y mejoren el acceso a los hospitales de especialidades. Material y métodos: Se evalúan las reformas de 2014 a la Ley General de Salud para entender su intención, que es fortalecer los sistemas estatales y la relación con la autoridad federal. Se discuten opciones para que los mecanismos de asignación incentiven mejor la atención primaria y el acceso a los tratamientos de especialidades para avanzar hacia mejores garantías de acceso a los servicios de salud. Conclusiones: Para convertir a los Regímenes Estatales de Protección Social en Salud en agentes para la expansión de los servicios debe superarse el enfoque programático para lograr una relación más eficaz entre la Federación y los Estados.

Abstract: Objective: To describe the mechanisms of allocation and purchase of the Seguro Popular program, the way they operate and how are controls applied.To discuss incentive schemes that can improve performance in general, strengthen primary care and improve access to specialty hospitals. Materials and methods: The 2014 reforms to the General Health Law are evaluated to understand their intent, which is to strengthen State systems and the relationship with the Federal authority. Options for allocation mechanisms to encourage better primary care and access to specialty treatments towards are discussed, to guarantee access to health services. Conclusions: To make State schemes of social protection in health agents for the expansion of services, the programmatic approach shall be replaced to achieve a more effective relationship between the Federation and the States.

[Methods for evaluating the economic efficiency of the project of PET-center's creation in conditions of a specialized medical institution].

This study evaluates the cost-effectiveness of the project of PET center's creation in the structure of specialized institution. To analyze the effectiveness and stability of obtained results there are used estimations of discounted factors, the flow and the amount of investments and the income at different discount rates. The figures revealed that the project should generate revenue as at zero discount rate it pays off.

Decreasing spine implant costs and inter-physician cost variation: the impact of programme of cost containment on implant expenditure in spinal surgery.

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre.

Lost in transition: the essential need for long-term follow-up clinic for blood and marrow transplantation survivors.

Because of expanding indications and improvements in supportive care, the utilization of blood and marrow cell transplantation (BMT) to treat various conditions is increasing exponentially, and currently more than 60,000 BMTs are performed annually worldwide. By the year 2030, it is projected that the number of BMT survivors will increase 5-fold, potentially resulting in one half of a million survivors in the United States alone. As the majority of survivors now live beyond the first 2 years after BMT, they are prone to a unique set of complications and late effects. Until recently, BMT experts assumed responsibility for almost all of the care for these survivors, but now oncologists/hematologists, pediatricians, and internists are involved frequently in offering specialized care and preventive services to these survivors. To integrate and translate into clinical practice the unique BMT survivorship issues with current preventive guidelines, a team effort is required. This can be facilitated by a dedicated "long-term-follow-up (LTFU)" clinic that provides lifelong care for BMT survivors. In this review, we first illustrate with clinical vignettes the need for LTFU and then focus upon the following: (1) types of LTFU clinic models, (2) challenges and possible solutions to the establishment of LTFU clinic, and (3) vulnerable transition periods.

[Future vascular medicine: inauguration of a cardiovascular hybrid concept]. / Gefäßmedizin von morgen: Vorstellung eines kardiovaskulären Hybrid-Care-Konzepts.

The demographic developments will lead to an exponential increase of cardiovascular diseases. Additionally, technical developments of conservative and invasive treatment modalities will be added to distinguished, organ-orientated therapeutic concepts. This will also require a new orientation of vascular services. This concept implies that specific contents are referred to and contained in partner specialties. Since the heart and vascular system function as an anatomic and functional union, implementation of vascular medicine within cardiovascular centres represents a logical consequence.

Future and training of craniofacial surgery in India.

Craniofacial surgery, in the strictest sense, is the surgery of structures above and behind the maxilla. Craniofacial surgery is not new to India and has been around for more than 4 decades now since the 1970s. Keeping in mind the promotion of the specialty in India, an Indian Craniofacial Foundation was launched in the year 2012 at the Annual Meeting of the Association of Plastic Surgeons of India. To develop a craniofacial center in India, the primary requirement is a source of funding. Several craniofacial centers, which are already running successfully in India, have amply demonstrated that this can be done in several ways. We would like to discuss here the 2 models of craniofacial service delivery and training that the authors have seen and experienced firsthand.

Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy.

Humanitarian cleft surgery has long been provided by teams from resource-rich countries traveling for short-term missions to resource-poor countries. After identifying an area of durable unmet need through surgical missions, Operation Smile constructed a permanent center for cleft care in Northeast India. The Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) uses a high-volume subspecialized institution to provide safe, quality, comprehensive, and cost-effective cleft care to a highly vulnerable patient population in Assam, India. The purpose of this study was to profile the expenses of several cleft missions carried out in Assam and to compare these to the expenditures of the permanent comprehensive cleft care center. We reviewed financial data from 4 Operation Smile missions in Assam between December 2009 and February 2011 and from the GCCCC for the 2012-2013 fiscal year. Expenses from the 2 models were categorized and compared. In the studied period, 33% of the mission expenses were spent locally compared to 94% of those of the center. The largest expenses in the mission model were air travel (48.8%) and hotel expenses (21.6%) for the team, whereas salaries (46.3%) and infrastructure costs (19.8%) made up the largest fractions of expenses in the center model. The evolution from mission-based care to a specialty hospital model in Guwahati incorporated a transition from vertical inputs to investments in infrastructure and human capital to create a sustainable local care delivery system.

Transfer rates from nonprocedure hospitals after initial admission and outcomes among elderly patients with acute myocardial infarction.

IMPORTANCE: It is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality. OBJECTIVES: To examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality. DESIGN, SETTING, AND PARTICIPANTS: We used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤ 20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55,962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction. MAIN OUTCOMES AND MEASURES: We compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year. RESULTS The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P < .001), percutaneous coronary intervention (P < .001), and coronary artery bypass graft surgery (P < .001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1% [2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P = .054) or 1 year (43.9% [2.3%], 43.6% [2.2%], 43.5% [2.4%], and 42.8% [2.2%], respectively; P < .001) for low, mid-low, mid-high, and high transfer groups. CONCLUSIONS AND RELEVANCE: Nonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.

Reporting of quality measures in gynecologic oncology programs at Prospective Payment System (PPS)-Exempt Cancer Hospitals: an early glimpse into a challenging initiative.

OBJECTIVE: The Affordable Care Act mandates the Prospective Payment System (PPS)-Exempt Cancer Hospitals Quality Reporting program. These 11 hospitals (which are paid fee-for-service rather than on a DRG system) began reporting measures (2 general safety, 2 breast, 1 colon) in 2013. Given this reporting mandate, we set out to determine whether the PPS-exempt gynecologic oncology programs could identify quality measures specific to the care of our patients. METHODS: A list of 12 quality measures specific to gynecologic oncology was created (from sources including the National Quality Forum and the SGO). Measures already in use were not included. The list was ranked by the gynecologic oncology program directors at the PPS-exempt hospitals. Descriptive statistics (including mean and SD for rankings) were utilized. RESULTS: Despite mandatory reporting of quality measures for PPS-exempt cancer hospitals, little consensus exists regarding specific gynecologic cancer measures. Documentation of debulking status, cancer survival, and offering minimally invasive surgery (for endometrial cancer) and intraperitoneal chemotherapy (for ovarian cancer) are important, but with widely variable responses (when ranked 1-12, standard deviations are 2-3). General issues regarding adherence to guidelines for the use of GCSF, documentation of functional status, and tracking of patient satisfaction scores were ranked the lowest. Three of the directors reported that their compensation is partially linked to quality outcomes. CONCLUSIONS: There is wide variability in ranking of quality measures, and may relate to provider or institutional factors. Despite the mandatory reporting in PPS-exempt cancer hospitals, work remains to define gynecologic cancer quality measures.

Spine surgery cost reduction at a specialized treatment center.

OBJECTIVE: To compare the estimated cost of treatment of spinal disorders to those of this treatment in a specialized center. METHODS: An evaluation of average treatment costs of 399 patients referred by a Health Insurance Company for evaluation and treatment at the Spine Treatment Reference Center of Hospital Israelita Albert Einstein. All patients presented with an indication for surgical treatment before being referred for assessment. Of the total number of patients referred, only 54 underwent surgical treatment and 112 received a conservative treatment with motor physical therapy and acupuncture. The costs of both treatments were calculated based on a previously agreed table of values for reimbursement for each phase of treatment. RESULTS: Patients treated non-surgically had an average treatment cost of US$ 1,650.00, while patients treated surgically had an average cost of US$ 18,520.00. The total estimated cost of the cohort of patients treated was US$ 1,184,810.00, which represents a 158.5% decrease relative to the total cost projected for these same patients if the initial type of treatment indicated were performed. CONCLUSION: Treatment carried out within a center specialized in treating spine pathologies has global costs lower than those regularly observed.

How much should be paid for specialised treatment?

English health policy has moved towards establishing specialist multi-disciplinary teams to care for patients suffering rare or particularly complex conditions. But the healthcare resource groups (HRGs), which form the basis of the prospective payment system for hospitals, do not explicitly account for specialist treatment. There is a risk, then, that hospitals in which specialist teams are based might be financially disadvantaged if patients requiring specialised care are more expensive to treat than others allocated to the same HRG. To assess this we estimate the additional costs associated with receipt of specialised care. We analyse costs for 12,154,599 patients treated in 163 English hospitals in fiscal year 2008/09 according to the type of specialised care received, if any. We account for the distributional features of patient cost data, and estimate ordinary least squares and generalised linear regression models with random effects to isolate what influence the hospital itself has on costs. We find that, for nineteen types of specialised care, patients do not have higher costs than others allocated to the same HRG. However, costs are higher if a patient has cancer, spinal, neurosciences, cystic fibrosis, children's, rheumatology, colorectal or orthopaedic specialised services. Hospitals might be paid a surcharge for providing these forms of specialised care. We also find substantial variation in the average cost of treatment across the hospital sector, due neither to the provision of specialised care nor to other characteristics of each hospital's patients.