Small Changes or Big Ones? The Case of Limits on Prescription Drug Copayments in California.

Despite standardization, advocates for various industries and certain patient needs continue to propose changes in coverage rules. Much of the advocacy is occurring at the state level with a focus on pharmaceutical coverage, such as equalizing cost sharing between oral and infused oncology drugs or setting limits on cost sharing for prescriptions.

Cost comparison of laparoscopic colectomy versus open colectomy in colon cancer.

BACKGROUND: Laparoscopic colectomy has been shown to be safe, oncologically comparable, and clinically beneficial over open colectomy for colon cancer, but utilization remains low. Objectives To evaluate the cost of laparoscopic colectomy vs open colectomy for colon cancer. METHODS: The authors conducted a retrospective claims data analysis using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The denominator population consisted of individuals who had commercial insurance coverage in all months of 2012 and >1 month in 2013 and pharmacy coverage throughout eligibility. The study population included individuals aged 18-64 years who were identified with colon cancer in 2013 and underwent an elective inpatient open colectomy or laparoscopic colectomy between January and November 2013. The cost and re-admission rate of open vs laparoscopic colectomy were compared after risk, adjusting for comorbidities, demographics, and geographic region. RESULTS: During the study period, 1299 elective inpatient colon cancer colectomies were performed (open, n = 558; laparoscopic, n = 741). After risk adjustment, the laparoscopic vs open group was shown to have lower re-admission rates (6.61 and 10.93 per 100 cases, respectively, p = .0165), lower average re-admission costs ($1676 and $3151, respectively, p = .0309), and lower 30-day post-discharge healthcare utilization costs ($4842 and $7121, respectively, p = .0047). Average allowed cost for the combined inpatient and 30-day post-discharge period was lower for laparoscopic vs open colectomy cases ($36,395 and $44,226, respectively, p < .001). CONCLUSIONS: The cost of laparoscopic colectomy was found to be statistically significantly less than that of open colectomy in patients undergoing elective surgery for colon cancer.

A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits.

BACKGROUND: The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery. METHODS: A Truven MarketScan® claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region. RESULTS: A total of 4615 colectomies were included-2054 (44.5 %) open and 2561 (55.5 %) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p < 0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9 % open vs. 2.0 % MIS, p < 0.001), higher overall complications (52.8 % open vs. 32.3 % MIS, p < 0.001), higher colorectal-specific complications (32.5 % open vs. 17.9 % MIS, p < 0.001), longer LOS (6.39 open vs. 4.44 days MIS, p < 0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p < 0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p = 0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution. CONCLUSIONS: In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.

Open vs. Minimally Invasive Hysterectomy: Commercially Insured Costs and Readmissions.

PURPOSE: To analyze commercial payer differences in the average costs and readmission rates between inpatient open hysterectomies and three types of outpatient hysterectomies: laparoscopic, laparoscopic assisted, and vaginal. DESIGN/METHODOLOGY: A retrospective claims data analysis was conducted using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database.The study was limited to women 18-64 years old who had pharmacy coverage, 12 months of commercial insurance coverage in 2012, and at least 1 month in 2013.Readmission costs were capped at $100,000 and outpatient hysterectomy costs were adjusted to be on the same basis as open costs based on the portion of cancer cases, geographic region, and risk profile. RESULTS: There were 21,926 hysterectomy cases meeting our criteria. Total average allowed costs for the day of surgery and 30 days following surgery were statistically significantly higher for inpatient open hysterectomies than outpatient hysterectomies (cost differences of $1,270 for laparoscopic, $2,764 for assisted laparoscopic, and $4,582 for vaginal; P<.001 for all comparisons). Readmission rates within 30 days following surgery were statistically significantly higher for inpatient open hysterectomies (3.05 per 100 cases) than those for outpatient laparoscopic (2.10 per 100 cases; P<.001) and assisted laparoscopic (2.17 per 100 cases; P=.01) hysterectomies, but not for vaginal hysterectomies (2.46 per 100 cases; P=.16). CONCLUSION: Inpatient open hysterectomies have statistically significantly higher average allowed costs than outpatient laparoscopic, laparoscopic assisted, and vaginal hysterectomies and statistically significantly higher readmission rates than outpatient laparoscopic and laparoscopic-assisted hysterectomies.

Cost Differences Between Open and Minimally Invasive Surgery.

PURPOSE: To analyze the cost difference between minimally invasive surgery (MIS) and open surgery from a commercial payer perspective for colectomy, ventral hernia repair, thoracic resection (resection of the lung), and hysterectomy. DESIGN: A retrospective claims data analysis was conducted using the 2011 and 2012 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. Study eligibility criteria included age 18-64 years, pharmacy coverage, ≥ 1 month of eligibility in 2012, and a claim coded with 1 of the 4 surgical procedures of interest; the index year was 2012. METHODOLOGY: Average allowed facility and professional costs were calculated during inpatient stay (or day of surgery for outpatient hysterectomy) and the 30 days after discharge for MIS vs open surgery. Cost difference was compared after adjusting for presence of cancer, geographic region, and risk profile (age, gender, and comorbidities). RESULTS: In total, 46,386 cases in the 2012 MarketScan database represented one of the surgeries of interest. The difference in average allowed surgical procedure cost (facility and professional) between open surgery vs adjusted MIS was $10,204 for colectomy; $3,721, ventral hernia repair; $12,989, thoracic resection; and $1,174, noncancer hysterectomy (P < .001 for all comparisons).The difference in average allowed cost in the 30 days after surgery between open surgery vs adjusted MIS was $1,494 for colectomy, $1,320 for ventral hernia repair, negative $711 for thoracic resection, and negative $425 for noncancer hysterectomy (P < .001 for all comparisons, except P = .487 for thoracic resection). CONCLUSION: MIS was associated with statistically significantly lower costs than open surgery for all 4 analyzed surgeries.