The effect of indication for surgery on Medicare payments following lower extremity bypass surgery
Elizabeth Andraska, BS1, Danielle Sutzko, MD, MS1, Andrew Gonzalez, MD, JD, MS2, Nicholas Osborne, MD, MS1.
1University of Michigan, Ann Arbor, MI, USA, 2University of Illinois, Chicago, IL, USA.
Objectives: Interest in improving health outcomes and minimizing cost has been gaining traction nationally. Peripheral arterial disease (PAD) represents a significant burden to society from both a quality and financial perspective, costing as much 2.3% of the annual Medicare budget. We examined the variation in Medicare payments associated with lower extremity bypass (LEB) surgery, focusing on total payments, including hospital payments, outlier payments, readmission payments and post-discharge care.
Methods: All patients undergoing LEB between 2009 and 2012 were identified in the MedPar database. Patients with concomitant supra-inguinal surgery, major amputation or atheroembolism were excluded. Risk and reliability adjusted mortality rates were generated for all hospitals. Hospital payment data was aggregated into DRG payments, outlier payments, physician payments, readmission payments and post-discharge payments. Hospital quintiles of cost were generated and variation in component payments were examined.
Results: A total of 116,334 patients in 2275 hospitals underwent LEB, including 25,366 (21.8%) who underwent femoral endarterectomy and 2481 (2.3%) who underwent minor amputations in combination. Indications for bypass included claudication (N=26,907, 23.1%), rest pain (18,489, 15.9%), tissue loss (35,841, 30.8%) and PAD unspecified (42,926, 36.9%). Median total Medicare payments for isolated LEB ($15,141, IQR $10851, $24581) were similar to combined LEB and endarterectomy ($15796, IQR $11595, $25530), however LEB and minor amputation was significantly more costly ($33807, IQR $22458, $53615), p<0.001. Table 1 shows the proportion of payments attributable to DRG, outlier, readmission, physician and post-discharge payments across hospital quintiles of total Medicare payments. There was wide variation in the distribution of payments. High payment hospitals appear to be more likely to treat a higher proportion of patients for tissue loss as compared to low-payment hospitals.
Conclusions: Medicare payments for LEB vary significantly across patients and hospitals. A significant source of variation appears to be the indication for treatment. Patients suffering from tissue loss requiring amputation have significantly higher payments. Hospital variation in Medicare payments can be attributed to multiple factors, including DRG, physician services, readmission and post-discharge payments. Efforts to address PAD quality and cost will need to account for the heterogeneity of this population and the high cost of tissue loss.
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