Episode costs for ambulatory stone surgery vary widely

A study analyzing variation in spending for patients undergoing ureteroscopy (URS) or shock wave lithotripsy (SWL) for urinary stone disease is a step towards helping urologists understand cost reduction opportunities as they face the possibility of payment bundling for these outpatient procedures, according to researchers from the University of Michigan, Ann Arbor.

Using claims data from the Michigan Value Collaborative, the investigators tabulated expenditures from the date of surgery to 30 days after discharge related to the index procedure, subsequent hospitalizations, professional services, and post-acute care. Then, they examined variation between hospitals in total episode and component expenditures and analyzed which factors were driving the variation. The dataset represented 9,449 URS procedures and 6,446 SWL procedures performed at 62 hospitals in Michigan between 2012 and 2015. The findings were presented at the World Congress of Endourology and SWL in Vancouver, Canada.

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The investigators found substantial variation in ambulatory surgical spending for urinary stone episodes across the Michigan hospitals, with a three-fold difference in mean total spending comparing the hospitals with the lowest and highest total per episode expenditure for either URS or SWL. With the hospitals grouped into four equal-sized quartiles based on total spending, most of the variation between the lowest and highest cost providers was explained by differences for the index procedure and post-acute care services.

“Taken together, these findings suggest that efforts to decrease provider variation in spending for the index procedure and post-acute care are likely to go a long way towards reducing the costs associated with surgical care for urinary stone disease. The findings from our study can also be used by policymakers involved in the design and implementation of payment bundles that aim to rein in spending for urinary stone strategy,” said senior author John M. Hollingsworth, MD.

Across all hospitals, mean total episode expenditure was $11,054 for URS and $7,668 for SWL. Looking at expenditures for each of the four components contributing to the total showed that hospitals in the highest quartile for total spending for SWL also had received significantly higher payments for the index procedure, professional services, subsequent hospitalization, and post-acute care compared with hospitals in the lowest spending quartile. For URS, payments for all components except subsequent hospitalization were significantly higher at the highest quartile hospitals compared with the lowest quartile hospitals.

Next: Index procedure associated with largest variation in payments between lowest and highest quartile hospitals

Among the four components and for both URS and SWL, the index procedure was associated with the largest variation in payments between the lowest and highest quartile hospitals, and it accounted for 68% and 44% of the variation in spending for URS and SWL, respectively. Mean payments for index procedure at the lowest and highest quartile hospitals were $4,995 and $7,936, respectively, for URS and $3,207 and $4,832 for SWL.

For both types of procedures, mean payment for post-acute care showed the second largest range between the lowest and highest quartile hospitals, and it accounted for 15% and 28% of the spending variation, respectively. Mean payments for post-acute care following URS at the lowest and highest quartile hospitals were $1,711 and $2,207, respectively, and were $1,104 and $2,138, respectively, following SWL.

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For URS, payments for professional services accounted for 11% of spending variation between the lowest and highest quartile hospitals while 6.0% of the variation was explained by payments for hospitalization. For SWL, 19.0% of the variation in spending was explained by payments for hospitalization and 9.0% was explained by payments for professional services.

“The occurrence of unplanned emergency department visits after surgery added substantially to the total expenditure per episode, but they were not significant drivers of spending variation between hospitals,” Dr. Hollingsworth said.