Payer-Negotiated Price Variation and Relationship to Surgical Outcomes for the Most Common Cancers at NCI-Designated Cancer Centers.

BACKGROUND: Federal rules mandate that hospitals publish payer-specific negotiated prices for all services. Little is known about variation in payer-negotiated prices for surgical oncology services or their relationship to clinical outcomes. We assessed variation in payer-negotiated prices associated with surgical care for common cancers at National Cancer Institute (NCI)-designated cancer centers and determined the effect of increasing payer-negotiated prices on the odds of morbidity and mortality. MATERIALS AND METHODS: A cross-sectional analysis of 63 NCI-designated cancer center websites was employed to assess variation in payer-negotiated prices. A retrospective cohort study of 15,013 Medicare beneficiaries undergoing surgery for colon, pancreas, or lung cancers at an NCI-designated cancer center between 2014 and 2018 was conducted to determine the relationship between payer-negotiated prices and clinical outcomes. The primary outcome was the effect of median payer-negotiated price on odds of a composite outcome of 30 days mortality and serious postoperative complications for each cancer cohort. RESULTS: Within-center prices differed by up to 48.8-fold, and between-center prices differed by up to 675-fold after accounting for geographic variation in costs of providing care. Among the 15,013 patients discharged from 20 different NCI-designated cancer centers, the effect of normalized median payer-negotiated price on the composite outcome was clinically negligible, but statistically significantly positive for colon [aOR 1.0094 (95% CI 1.0051-1.0138)], lung [aOR 1.0145 (1.0083-1.0206)], and pancreas [aOR 1.0080 (1.0040-1.0120)] cancer cohorts. CONCLUSIONS: Payer-negotiated prices are statistically significantly but not clinically meaningfully related to morbidity and mortality for the surgical treatment of common cancers. Higher payer-negotiated prices are likely due to factors other than clinical quality.

Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks.

Importance: Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. Objective: To quantify low-volume surgery and associated outcomes within hospital networks. Design, Setting, and Participants: This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Exposure: Receipt of surgery in a low-volume hospital within a network. Main Outcomes and Measures: Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). Results: In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Conclusions and Relevance: Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.

Optimizing care delivery in expanding health systems: Views from clinical leaders.

INTRODUCTION: In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored. METHODS: Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis. RESULTS: Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality. CONCLUSIONS: Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.

Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.

BACKGROUND: Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. METHODS: A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes. RESULTS: In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001). CONCLUSIONS: The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.

Hospital performance in a statewide commercial insurer episode-based incentive program.

OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

The combined effect of race, dual-eligibility and neighborhood deprivation on medicare spending after cancer surgery.

INTRODUCTION: Disparities in clinical outcomes following high-risk cancer operations are well documented, but, whether these disparities contribute to higher Medicare spending is unknown. METHODS: Using 100% Medicare claims, White and Black beneficiaries undergoing complex cancer surgery between 2016 and 2018 with dual eligibility status and census tract Area Deprivation Index score were included. Linear regression was used to assess the association of race, dual-eligibility, and neighborhood deprivation on Medicare payments. RESULT: Overall, 98,725 White(93.5%) and 6900 Black(6.5%) patients were included. Black beneficiaries were more likely to live in the most deprived neighborhoods(33.4% vs. 13.6%; P < 0.001) and be dual-eligible(26.6% vs. 8.5%; P < 0.001) compared to White beneficiares. Overall, Medicare spending was higher for Black compared to White patients($27,291 vs. 26,465; P < 0.001). Notably, when comparing Black dual-eligible patients living in the most deprived neighborhoods to White non-dual eligible patients living in the least deprived spending($29,507 vs. $25,596; abs diff $3911; P < 0.001). CONCLUSION: In this study, Medicare spending was significantly higher for Black patients undergoing complex cancer operations compared to White patients due to higher index hospitalization and post-discharge care payments.

Treatment patterns and survival in older adults with unresected nonmetastatic biliary tract cancers.

INTRODUCTION: The optimal treatment for unresected nonmetastatic biliary tract cancer (uBTC) is not well-established. The objective of this study was to analyze the treatment patterns and compare the differences in overall survival (OS) between different treatment strategies amongst older adults with uBTC. MATERIALS AND METHODS: We identified patients aged ≥65 years with uBTC using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2004-2015). Treatments were classified into chemotherapy, chemoradiotherapy, and radiotherapy. The primary outcome was OS. The differences in OS were analyzed using Kaplan-Meier curves and multivariable Cox proportional hazard regression. RESULTS: A total of 4352 patients with uBTC were included. The median age was 80 years and median OS was 4.1 months. Most patients (67.3%, n = 2931) received no treatment, 19.1% chemotherapy (n = 833), 8.1% chemoradiotherapy (n = 354), and 5.4% radiotherapy alone (n = 234). Patients receiving no treatment were older and had more comorbidities. Chemotherapy was associated with significantly longer OS than no treatment in uBTC (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.95), but no difference was found in the subgroups of intrahepatic cholangiocarcinoma (iCCA; HR 0.87, 95% CI 0.75-1.00) and gallbladder carcinoma (GBC; HR 1.09, 95% CI 0.86-1.39). In the sensitivity analyses, capecitabine-based chemoradiotherapy showed significantly longer OS in uBTC compared to chemotherapy (adjusted HR 0.71, 95% CI 0.53-0.95). DISCUSSION: A minority of older patients with uBTC receive systemic treatments. Chemotherapy was associated with longer OS compared to no treatment in uBTC, but not in the subgroups of iCCA and GBC. The efficacy of chemoradiotherapy, especially in perihilar cholangiocarcinoma using capecitabine-based chemoradiotherapy, may be further evaluated in prospective clinical trials.

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending.

Importance: Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate. Objective: To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement. Design, Setting, and Participants: This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022. Exposures: Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey. Main Outcomes and Measures: Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics. Results: A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001). Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

Evaluation of Prices for Surgical Procedures Within and Outside Hospital Networks in the US.

This economic evaluation examines variations in prices for surgical procedures under the Hospital Price Transparency Rule at hospitals within and outside hospital networks in the US.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Neighborhood Deprivation, Hospital Quality, and Mortality After Cancer Surgery.

OBJECTIVE: To evaluate if receipt of complex cancer surgery at high-quality hospitals is associated with a reduction in disparities between individuals living in the most and least deprived neighborhoods. BACKGROUND: The association between social risk factors and worse surgical outcomes for patients undergoing high-risk cancer operations is well documented. To what extent neighborhood socioeconomic deprivation as an isolated social risk factor known to be associated with worse outcomes can be mitigated by hospital quality is less known. METHODS: Using 100% Medicare fee-for-service claims, we analyzed data on 212,962 Medicare beneficiaries more than age 65 undergoing liver resection, rectal resection, lung resection, esophagectomy, and pancreaticoduodenectomy for cancer between 2014 and 2018. Clinical risk-adjusted 30-day postoperative mortality rates were used to stratify hospitals into quintiles of quality. Beneficiaries were stratified into quintiles based on census tract Area Deprivation Index. The association of hospital quality and neighborhood deprivation with 30-day mortality was assessed using logistic regression. RESULTS: There were 212,962 patients in the cohort including 109,419 (51.4%) men with a mean (SD) age of 73.8 (5.9) years old. At low-quality hospitals, patients living in the most deprived areas had significantly higher risk-adjusted mortality than those from the least deprived areas for all procedures; esophagectomy: 22.3% versus 20.7%; P <0.003, liver resection 19.3% versus 16.4%; P <0.001, pancreatic resection 15.9% versus 12.9%; P <0.001, lung resection 8.3% versus 7.8%; P <0.001, rectal resection 8.8% versus 8.1%; P <0.001. Surgery at a high-quality hospitals was associated with no significant differences in mortality between individuals living in the most compared with least deprived neighborhoods for esophagectomy, rectal resection, liver resection, and pancreatectomy. For example, the adjusted odds of mortality between individuals living in the most deprived compared with least deprived neighborhoods following esophagectomy at low-quality hospitals (odds ratio=1.22, 95% CI: 1.14-1.31, P <0.001) was higher than at high-quality hospitals (odds ratio=0.98, 95% CI: 0.94-1.02, P =0.03). CONCLUSION AND RELEVANCE: Receipt of complex cancer surgery at a high-quality hospital was associated with no significant differences in mortality between individuals living in the most deprived neighborhoods compared with least deprived. Initiatives to increase access referrals to high-quality hospitals for patients from high deprivation levels may improve outcomes and contribute to mitigating disparities.

Area Deprivation and Medicare Spending for Coronary Artery Bypass Grafting: Insights From Michigan.

BACKGROUND: Prior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for patients undergoing coronary artery bypass grafting (CABG). The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care after isolated CABG. METHODS: We linked clinical registry data from 8728 isolated CABG procedures from January 1, 2012, to December 31, 2018, to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against nondeprived patients as well as component spending categories: index hospitalization, professional services, post acute care, and readmissions. RESULTS: A total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8728 patients in the sample was $55 258 (SD, $26 252). Socioeconomically deprived patients had higher overall 90-day spending compared with nondeprived patients ($61 579 vs $54 557; difference, $3003; P = .001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference, $1284; P = .005), professional services (difference, $379; P = .002), and readmissions (difference, $1188; P = .008). Inpatient rehabilitation was the only significant difference in post-acute care spending (difference, $469; P = .011). CONCLUSIONS: Medicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.

Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals.

IMPORTANCE: Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk. OBJECTIVE: To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021. EXPOSURES: Medicare and Medicaid DE status and hospital quality. MAIN OUTCOMES AND MEASURES: Postoperative complications, readmission, and mortality by DE status and hospital quality. RESULTS: Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals. CONCLUSIONS AND RELEVANCE: The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.

Variation in Surgical Spending Among the Highest Quality Hospitals for Cancer Surgery.

OBJECTIVE: This study evaluates the variation in spending by the highest-quality hospitals performing complex cancer surgery in the United States. SUMMARY BACKGROUND DATA: As mortality rates for high-risk cancer surgery have improved, increased attention has focused on other elements of quality, such as complications. However, high-value surgical care requires both high-quality care and cost savings. Therefore, understanding any residual cost variation among high-quality hospitals is essential to better direct efforts to achieve efficient, high-value care. METHODS: Medicare beneficiaries age 65 to 99 who underwent surgery for pancreas, esophageal, lung, rectal, and colon cancer from 2014 to 2016 were identified. The highest-quality hospitals were identified as those in the quintile with the lowest risk- and reliability-adjusted serious complication rates for each operation. Within this cohort of high-quality hospitals, 30-day total episode, index hospitalization, physician, postacute care, and readmis-sion spending were analyzed. Logistic regression models were utilized to estimate the probability of postoperative outcomes and post-discharge resource utilization. RESULTS: A total of 43,007 Medicare patients underwent either pancreas, esophageal, lung, rectal, or colon resection for cancer at a hospital within the highest-quality quintile. Among the highest quality hospitals, total episode spending ranged from $18,712 for colectomy to $38,054 for esophagectomy. Spending between the lowest- and highest spending hospitals varied from $1207 [confidence intervals (CI 95% ) $1195-$1220] or 6.6% of total episode spending in the lowest tertile for colectomy to $5706 (CI 95% $5,506-$5906) or 16.1% of total episode spending in the lowest tertile for esophagectomy. The largest component of variation was from postacute care spending followed by readmission. For all operations, the risk-adjusted rate of postacute care facility utilization was lower among the lowest spending hospitals compared to the highest spending hospitals. For example, for pancreas the lowest-spending hospitals on average discharged patients to a postacute care facility at a rate of 18,6% (CI 95% 16.2-20.9) compared to 31.0% (CI 95% 28.2-33.9) in the highest-spending hospitals. In all operations, the risk-adjusted readmission rate was lower among the lowest-spending hospitals compared to the highest-spending hospitals. For instance, within the esophagus cohort, the lowest-spending hospitals had an average risk-adjusted readmission rate of 17.3% compared to 29.4% in the highest spending hospitals ( P < .001). CONCLUSIONS AND RELEVANCE: Even among the highest-quality hospitals, significant cost variation persists among cancer operations. Postacute care variation, rather than residual variation in complication rates, explains the majority of this variation and represents an immediately actionable target for increased cost-efficiency.

High Socioeconomic Deprivation and Coronary Artery Bypass Grafting Outcomes: Insights From Michigan.

BACKGROUND: Cardiovascular outcomes are worse among individuals from areas with limited socioeconomic resources. This study evaluated the relationship between high socioeconomic deprivation and isolated coronary artery bypass grafting (CABG) outcomes. METHODS: We linked statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database data to Medicare Fee-for-Service records for 10 423 Michigan residents undergoing isolated CABG between January 2012 and December 2018. High socioeconomic deprivation was defined as residing in the highest decile of the ZIP Code-level area deprivation index (ADI). Multivariable logistic regression estimated the relationship between top ADI decile and major morbidity, in-hospital mortality, and operative mortality. Survival analyses evaluated long-term survival comparing patients in the top vs not in the top ADI decile. RESULTS: A total of 1036 patients were in the top decile of ADI (ADI >82.4), and they were more likely to be female, Black, and have a higher predicted risk of mortality. Patients in the top ADI decile had significantly higher rates of major morbidity (17.4% vs 11.4%; adjusted odds ratio, 1.26; 95% CI, 1.04-1.54; P = .021) and in-hospital mortality (3.2% vs 1.3%, adjusted odds ratio, 1.84; 95% CI, 1.18-2.86, P = .007) but not operative mortality. The adjusted hazard of mortality was 16% higher for patients residing in the top ADI decile (95% CI, 1.01-1.33; P = .032). CONCLUSIONS: Isolated CABG patients residing in the highest areas of socioeconomic deprivation differed with respect to demographic and clinical characteristics and experienced worse short- and long-term outcomes compared with those not in the top ADI decile.

The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.

Wide Variation in Surgical Spending Within Hospital Systems: A Missed Opportunity for Bundled Payment Success.

OBJECTIVE: We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems. SUMMARY OF BACKGROUND DATA: Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost. METHODS: Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level. RESULTS: Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272-$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545-$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals. CONCLUSIONS: Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs.

Variations in surgical spending within hospital systems for complex cancer surgery.

BACKGROUND: Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery. METHODS: Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels. RESULTS: Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy. CONCLUSIONS: In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.

Sources of Hospital Variation in Postacute Care Spending After Cardiac Surgery.

BACKGROUND: Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization. METHODS AND RESULTS: A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes. CONCLUSIONS: There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.