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.
For more information:
http://www.hopkinsmedicine.org/surgery/faculty/Makary
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