Cost Transparency in Neurosurgery: A Single-Institution Analysis of Patient Out-of-Pocket Spending in 13 673 Consecutive Neurosurgery Cases.

BACKGROUND: Patient out-of-pocket (OOP) spending is an increasingly discussed topic; however, there is minimal data available on the patient financial burden of surgical procedures. OBJECTIVE: To analyze hospital and surgeon expected payment data and patient OOP spending in neurosurgery. METHODS: This is a retrospective cohort study of neurosurgical patients at a tertiary-referral center from 2013 to 2016. Expected payments, reflecting negotiated costs-of-care, as well as actual patient OOP payments for hospital care and surgeon professional fees were analyzed. A 4-tiered model of patient OOP cost sharing and a multivariate model of patient expected payments were created. RESULTS: A total of 13 673 consecutive neurosurgical cases were analyzed. Patient age, insurance type, case category, severity of illness, length of stay (LOS), and elective case status were significant predictors of increased expected payments (P < .05). Craniotomy ($53 397 ± 811) and posterior spinal fusion ($48 329 ± 864) were associated with the highest expected payments. In a model of patient OOP cost sharing, nearly all neurosurgical procedures exceeded yearly OOP maximums for Healthcare Marketplace plans. Mean patient payments for hospital care and surgeon professional fees were the highest for anterior/lateral spinal fusion cases for commercially insured patients ($1662 ± 165). Mean expected payments and mean patient payments for commercially insured patients increased significantly from 2013 to 2016 (P < .05). CONCLUSION: Expected payments and patient OOP spending for commercially insured patients significantly increased from 2013 to 2016, representing increased healthcare costs and patient cost sharing in an evolving healthcare environment. Patients and providers can consider this information prior to surgery to better anticipate the individual financial burden for neurosurgical care.

Nationwide Analysis of Cost Variation for Treatment of Aneurysmal Subarachnoid Hemorrhage.

Background and Purpose- Aneurysmal subarachnoid hemorrhage (aSAH) has a high healthcare cost burden. Methods- We performed a cross-sectional analysis of the costs of clipping and coiling of aSAH using the National Inpatient Sample and Vizient databases. We conducted multiple regression analyses to estimate national costs and study associations between patient demographic, clinical, and hospital factors and treatment costs. Results- We identified 23 324 ruptured aneurysm patients in the National Inpatient Sample (2002-2013) and found mean inflation-adjusted costs for clipping increased 41.0% ($66 358±1354-$93 597±2339), whereas costs for coiling increased 38.9% ($62 972±2657-$87 441±2382). Multivariate analysis showed that age, length of stay, insurance, comorbidities, risk of mortality, and urban teaching hospital status were associated with higher hospital costs for clipping and coiling (all P<0.05). In the Vizient database (2013-2015), costs for clipping and coiling increased 11% and 5%, respectively. Both databases demonstrated that the western United States had the highest health expenditures for aSAH (P<0.05). Conclusions- Findings show substantial cost increases and regional cost disparities for aSAH treatments. Patient and hospital factors copredict higher costs for aSAH procedures. Interhospital and regional cost variations open the door for cost-containment strategic development.

Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review.

OBJECTIVE With drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth. METHODS For 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors' institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time. RESULTS In the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain ($1151 ± $209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from $598 to $698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% ($991 in 2013 to $1403 in 2016). CONCLUSIONS Even after controlling for inflation, case-mix differences, and partial fiscal periods, OOP spending for cranial neurosurgery patients significantly increased from 2013 to 2016. The mean OOP spending for commercially insured neurosurgical patients exceeded $1400 in 2016, with an average annual growth rate of 13%. As patient cost sharing in health insurance plans becomes more prevalent, patients and providers must consider the potential financial burden for patients receiving specialized neurosurgical care.

Trends in Utilization and Cost of Cervical Spine Surgery Using the National Inpatient Sample Database, 2001 to 2013.

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation. SUMMARY OF BACKGROUND DATA: There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level. METHODS: We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region. RESULTS: The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast. CONCLUSION: The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery. LEVEL OF EVIDENCE: 3.

Analysis of Cost Variation in Craniotomy for Tumor Using 2 National Databases.

BACKGROUND: There is a significant increase and large variation in craniotomy costs. However, the causes of cost differences in craniotomies remain poorly understood. OBJECTIVE: To examine the patient and hospital factors that underlie the cost variation in tumor craniotomies using 2 national databases: the National Inpatient Sample (NIS) and Vizient, Inc. (Irving, Texas). METHODS: For 41 483 patients who underwent primary surgery for supratentorial brain tumors from 2001 to 2013 in the NIS, we created univariate and multivariate models to evaluate the effect of several patient factors and hospital factors on total hospital cost. Similarly, we performed multivariate analysis with 15 087 cases in the Vizient 2012 to 2015 database. RESULTS: In the NIS, the mean inflation-adjusted cost per tumor craniotomy increased 30%, from $23 021 in 2001 to $29 971 in 2013. In 2001, the highest cost region was the Northeast ($24 486 ± $1184), and by 2013 the western United States was the highest cost region ($36 058 ± $1684). Multivariate analyses with NIS data showed that male gender, white race, private insurance, higher mortality risk, higher severity of illness, longer length of stay, elective admissions, higher wage index, urban teaching hospitals, and hospitals in the western United States were associated with higher tumor craniotomy costs (all P < .05). Multivariate analyses with Vizient data confirmed that longer length of stay and the western United States were significantly associated with higher costs (P < .001). CONCLUSION: After controlling for patient/clinical factors, hospital type, bed size, and wage index, hospitals in the western United States had higher costs than those in other parts of the country, based on analyses from 2 separate national databases.

Operating room waste: disposable supply utilization in neurosurgical procedures.

OBJECTIVE Disposable supplies constitute a large portion of operating room (OR) costs and are often left over at the end of a surgical case. Despite financial and environmental implications of such waste, there has been little evaluation of OR supply utilization. The goal of this study was to quantify the utilization of disposable supplies and the costs associated with opened but unused items (i.e., "waste") in neurosurgical procedures. METHODS Every disposable supply that was unused at the end of surgery was quantified through direct observation of 58 neurosurgical cases at the University of California, San Francisco, in August 2015. Item costs (in US dollars) were determined from the authors' supply catalog, and statistical analyses were performed. RESULTS Across 58 procedures (36 cranial, 22 spinal), the average cost of unused supplies was $653 (range $89-$3640, median $448, interquartile range $230-$810), or 13.1% of total surgical supply cost. Univariate analyses revealed that case type (cranial versus spinal), case category (vascular, tumor, functional, instrumented, and noninstrumented spine), and surgeon were important predictors of the percentage of unused surgical supply cost. Case length and years of surgical training did not affect the percentage of unused supply cost. Accounting for the different case distribution in the 58 selected cases, the authors estimate approximately $968 of OR waste per case, $242,968 per month, and $2.9 million per year, for their neurosurgical department. CONCLUSIONS This study shows a large variation and significant magnitude of OR waste in neurosurgical procedures. At the authors' institution, they recommend price transparency, education about OR waste to surgeons and nurses, preference card reviews, and clarification of supplies that should be opened versus available as needed to reduce waste.