October 25, 2016
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New MD Plan Not Good For Obese Blacks

Pay-for-performance reimbursement of surgeons, intended to reward 
doctors and hospitals for good patient outcomes, may instead be 
creating financial incentives for discriminating against obese 
patients, who are much more likely to suffer expensive complications 
after even the most routine surgeries, according to new Johns Hopkins research.

Medicare and Medicaid, for example, are increasingly using 
pay-for-performance formulas to cut doctor's pay when their patients 
develop infections after surgery. But the Johns Hopkins researchers 
say there could be negative unintended consequences, because obese 
patients, who make up about one-third of the population, are at 
significantly greater risk of complications - notably surgical site 
infections - following appendectomy and gallbladder removal surgery 
than non-obese patients. They also cost thousands more dollars to 
treat than the non-obese.

The new research is scheduled to be presented at Digestive Disease 
Week, the nation's largest gastrointestinal medical conference, which 
runs from May 1 to May 5 in New Orleans.

"This is a government policy that promotes patient selection and 
discrimination," says Martin A. Makary, M.D., M.P.H., an associate 
professor of surgery and health policy at the Johns Hopkins 
University School of Medicine, and the study's leader. "The policy 
incentivizes doctors to pass on, stall or delay treatment of obese 
patients, many of whom are minorities."

Makary suggests that the potential discrimination will 
disproportionately affect African-Americans, whose rates of obesity 
are higher than in the white population. An estimated 65 percent of 
African-American women are overweight in the United States compared 
to 20 percent of white men. In this way, Makary says, flawed 
pay-for-performance policies hurt minority populations -- and the 
doctors who treat them -- the most.

Makary says hospitals and doctors should be held responsible for 
preventing surgical complications. But, he says, any 
pay-for-performance system needs to look beyond complication rates 
and take into account the increased risks and costs known to be 
associated with obesity.

"Rewarding providers based on outcomes is good when the outcomes are 
adjusted for case complexity or co-moribidities," Makary says. "But 
it can be discriminatory and create perverse incentives when metrics 
aren't adjusted. And what is the most prevalent and leading 
co-morbidity in America that skews outcome< Hands down, it's obesity."

Makary and his colleagues examined insurance claims for 35,096 
patients who underwent gallbladder removal and 6,854 patients who 
underwent appendectomy from 2002 to 2008. They compared 30-day 
complications as well as total direct medical costs following surgery 
for obese and non-obese patients.

They found that obese patients were 27 percent more likely than 
non-obese patients to have complications following gallbladder 
surgery and 11 percent more likely to have complications following an 
appendectomy. These complications mean obese patients end up costing 
more to treat, with median total inpatient costs for basic 
gallbladder removal $2,978 higher for obese patients, and $1,621 
higher for obese patients who had appendectomy.

Obese patients undergoing appendectomy had longer hospital stays and 
higher rates of reoperation, infection and hemorrhage than non-obese 
patients, the researchers found. Obese patients who had their 
gallbladders removed saw higher rates of blood clots, reoperation and 
infection. Surgery is particularly difficult on obese patients, the 
authors note, especially procedures performed in the abdominal region 
where fat is disproportionately located. Operations in the obese 
often take longer and require larger wounds. Obese patients may also 
present at later stages of disease, making surgery and subsequent 
care more complex.

Other Johns Hopkins faculty members involved in the study include 
Kenzo Hirose, M.D.; Andrew Shore, Ph.D.; Elizabeth Wick, M.D., and 
Jonathan P. Weiner, Dr.P.H.

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