Each year in the United States, more than 50,000 Medicare patients die undergoing inpatient surgery. Evidence of wide variations across providers suggests substantial room for improvement. To improve surgical care in the elderly, the Center for Medicare and Medicaid Services (CMS) has launched several policies. However, the extent to which these policies improve outcomes and reduce costs in surgery is unknown. We therefore propose a systematic evaluation of the impact of several policy options on the quality and cost of surgical care in the national Medicare population. With this goal in mind, our current proposal has the following aims:
Aim 1. To evaluate the impact of CMS improvement policies on surgical outcomes. We will conduct evaluations of pay-for-performance, selective referral, bundled payment, and outcomes feedback in the national Medicare population. For each policy approach, we will take advantage of a natural experiment (i.e., a specific program or policy implemented in the last 5 years). To assess outcomes, we will use risk-adjusted mortality and complications for the procedures specifically targeted by the policy. To better control for hospital case-mix and secular trends, we will use a difference-in-difference methodology.
Aim 2. To evaluate the spillover effects of these CMS policies on untargeted surgical conditions. Using national Medicare data, we will examine outcomes for untargeted procedures for which patients receive care from the same surgeons or depend on the same hospital resources. We will assess whether these policies resulted in beneficial spillover effects or caused unintended harm as resources were diverted to the targeted conditions.
Aim 3. To evaluate the impact of these policies on Medicare payments around the surgical episode. We will evaluate Medicare payments for the full range of services that can be linked to complications and poor quality care. We will include payments to the hospital, physicians, readmissions, and post-acute care. The results of this study will facilitate evidence-based policymaking by CMS and other payers. As effective policies for improving care are implemented, surgical patients will be the ultimate beneficiaries of this research.

Public Health Relevance

This study will have immediate real-world impact for CMS policymakers and surgical patients. The results of this proposal will provide CMS with data on the comparative effectiveness of various initiatives for improving quality and decreasing costs. As effective strategies for improving care are implemented by CMS and other payers, surgical patients will be the ultimate beneficiaries of this research.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Project (R01)
Project #
5R01AG039434-02
Application #
8253680
Study Section
Special Emphasis Panel (ZRG1-HDM-R (02))
Program Officer
Baker, Colin S
Project Start
2011-04-15
Project End
2015-03-31
Budget Start
2012-04-01
Budget End
2013-03-31
Support Year
2
Fiscal Year
2012
Total Cost
$318,775
Indirect Cost
$113,775
Name
University of Michigan Ann Arbor
Department
Surgery
Type
Schools of Medicine
DUNS #
073133571
City
Ann Arbor
State
MI
Country
United States
Zip Code
48109
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Gonzalez, Andrew A; Girotti, Micah E; Shih, Terry et al. (2014) Reliability of hospital readmission rates in vascular surgery. J Vasc Surg 59:1638-43
Nicholas, Lauren Hersch; Dimick, Justin B (2013) Bariatric surgery in minority patients before and after implementation of a centers of excellence program. JAMA 310:1399-400
Dimick, Justin B; Nicholas, Lauren H; Ryan, Andrew M et al. (2013) Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 309:792-9