Back to 2016 Karmody Posters

OBJECTIVES- There is growing interest in providing high quality and low cost care to Americans. Government and private insurers are pursuing avenues to measure not only how well hospitals are performing surgeries, but also at what cost. We sought to examine the variation in Medicare costs associated with open and endovascular abdominal aortic aneurysm (AAA) repair, particularly focusing on total payments, including hospital payments, outlier payments, readmission payments and post-discharge care.
METHODS- All patients undergoing open infrarenal AAA repair between 2009 and 2012 were identified using the Medicare Provider Analysis and Review (MEDPAR) file. Risk and reliability adjusted mortality rates were generated for all hospitals. Hospital payment data was aggregated into diagnosis related group (DRG) payments, outlier payments, physician services, readmission payments and post-discharge payments. Hospital quintiles of cost were then generated and variations in component costs were examined.
RESULTS- A total of 49,951 patients underwent open infrarenal AAA repair and 106,657 patients underwent EVAR between 2009 and 2012, in a total of 1,983 hospitals. Median total Medicare payments for open AAA repair were \,674 (IQR \,396, \,129) and \,487 (IQR \,571, \,070) for EVAR. Table 1 shows the proportion of payments attributable to DRG, outlier, readmission, physician and post-discharge payments. There was wide variation in the distribution of payments. Although low volume hospitals appeared to have lower cost (p<0.001), hospital risk and reliability-adjust mortality (p<0.001) was minimally different between groups.
CONCLUSIONS- Medicare payments for AAA repair vary significantly across the country. This variation can be broken down into costs incurred at the hospital (DRG, outlier, physician services and readmissions) and outside the hospital (post-discharge care). Variation across all these components appears to play an important role in variation in Medicare payments. Future work is necessary to understand the intersection of cost and quality.

Average Medicare Payments For Different Components Of Care Around Open AAA Repair, 2009-2012

Open AAA Repair	.	Quintile Of Total Costs	.	.	.
	1	2	3	4	5
DRG Payments	17,804	21,202	22,617	24,300	29,592
Outlier Payments	178	869	1,606	2,690	6,870
Readmission Payments	594	1,270	1,644	2,448	3,908
Physician Services	1,916	2,870	3,780	4,303	6,426
Post-discharge Payments	950	1,944	3,042	4,411	7,174
Total Payments	21,442	28,155	32,689	38,152	53,970
Volume (Repairs Per Year)	2.9	6.075	7.25	8.25	7
Risk and Reliability Adjusted Mortality	11.20%	11.40%	11.40%	11.40%	11.80%

Average Medicare Payments For Different Components Of Care Around EVAR, 2009-2012

EVAR	.	Quintiles of Total Costs	.	.	.
	1	2	3	4	5
DRG Payments	15,748	16,375	16,769	17,239	20,082
Outlier Payments	98	360	694	1,193	3,370
Readmission Payments	454	944	1,026	1,429	2,746
Physician Services	1,708	2,427	2,777	3,066	4,183
Post-Discharge Payments	385	877	1,242	1,563	3,017
Total Payments	18,393	20,983	22,508	24,490	33,398
Volume (Repairs Per Year)	8.75	15.75	19.25	18.5	12
Risk and Reliability Adjusted Mortality	2.60%	2.60%	2.70%	2.80%	2.90%