Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications

Our plain-English summary of Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications, by M.H. Squires, C.A. Staley, W. Knechtle, et al (Annals of Surgical Oncology, 2015).

The study

• Authors: M.H. Squires, C.A. Staley, W. Knechtle, J.H. Winer, M.C. Russell, S. Perez, J.F. Sweeney, S.K. Maithel, C.A. Staley
• Journal: Annals of Surgical Oncology
• Published: 2015;22(5):1739-45
• Cited by: 31 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications.

Methods: Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed.

Results: A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients.

Conclusions: CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.

In plain English

This single-institution study examined 64 patients who had cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) at a U.S. academic center from January 2009 to June 2013, analyzing hospital finances for the 56 with financial data. Only 3 patients (5 %) had mesothelioma. Most had appendiceal or colorectal tumors, and the article gave no separate results for the mesothelioma patients and did not discuss asbestos. Complications occurred in 42 of the 64 patients (66 %), 13 of them major. Average net profit was $14,523 per patient. Medicare/Medicaid reimbursed significantly less than private insurance ($30,713 vs $80,747). Medicare/Medicaid patients were associated with an average hospital loss of more than $17,000 per patient. Major complications were associated with higher costs ($59,877 vs $46,650). Among patients with major complications, the 7 privately insured patients averaged a $36,285 profit, while the 4 Medicare/Medicaid patients averaged a $54,274 loss. The authors concluded the procedure appeared profitable in privately insured patients but lost money in Medicare/Medicaid patients. They named the single-institution data and small subgroups as limitations.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Single-institution financial analysis. Patients were identified from a prospectively maintained database, and cost and reimbursement data were analyzed retrospectively.
• Who was studied: 64 patients who underwent CRS/HIPEC at one U.S. academic institution (Emory University) from January 2009 to June 2013. Tumor types were appendiceal (40), colorectal (16), goblet cell (5) and mesothelioma (3). Financial data were available for 56 of them: 37 with private insurance and 19 with Medicare/Medicaid.
• Exposure: Not an asbestos exposure study. The factors compared were insurance provider type (private vs Medicare/Medicaid) and postoperative complications (Clavien–Dindo grades). All patients received HIPEC with intraperitoneal mitomycin-C.
• Main results:
  • Among all 64 patients, 42 (66 %) had postoperative complications, including 13 (20 %) with major (Clavien grade III–IV) complications. No 30-day deaths occurred.
  • Financial data were available for 56 of the 64 patients (37 privately insured, 19 Medicare/Medicaid).
  • Among the 56 patients with financial data, the average net profit margin was $14,523 (plus or minus $35,660) per patient. Average total hospital cost was nearly $50,000 ($49,248).
  • Despite similar hospital costs, Medicare/Medicaid patients (n = 19) were reimbursed significantly less than privately insured patients (n = 37): $30,713 vs $80,747, p less than 0.001.
  • On average, Medicare/Medicaid patients were associated with a net loss to the hospital of more than $17,000 per patient ($17,342 in Table 3).
  • Minor complications (Clavien grade I–II) were not associated with significantly increased costs.
  • Patients with major complications (n = 11 with financial data) had significantly higher average total hospital costs than those without major complications (n = 45): $59,877 vs $46,650, p = 0.01.
  • Among patients with major complications, privately insured patients (n = 7) had an average net profit margin of $36,285. Medicare/Medicaid patients (n = 4) had an average net loss of $54,274 (p = 0.003).
  • Medicare/Medicaid patients without major complications (n = 15) were still associated with an average net loss of more than $12,000 per patient.
• The authors' conclusion: The authors concluded that CRS/HIPEC appeared profitable in privately insured patients but lost money on average in Medicare/Medicaid patients. They expected complications to be negatively associated with profit under a future bundled-reimbursement system, and said hospitals must focus on value, decreasing costs and minimizing complications.
• Limitations the authors state:
  • Financial data came from a single institution, and the numbers of patients in subset analyses were small.
  • Outpatient costs after discharge were not included.
  • Costs of 30-day readmissions were not included.
  • The results may not reflect the experience of well-established, high-volume HIPEC centers.

Topics

Medical terms in this study, explained in our Lexicon: HIPEC, Cytoreductive Surgery, Histology, Mesothelioma.

Related studies

• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) — M.F. Nunez, A. Sardi, et al. (2015)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome — C. Ihemelandu, L. Bijelic, et al. (2015)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)

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