Aligning Incentives in the Management of Inguinal Hernia: The Impact of the Payment Model
ABSTRACT The Affordable Care Act has stimulated discussion to find feasible, alternate payment models. Adopting a global payment (GP) mechanism may dampen the high number of procedures incentivized by the fee-for-service (FFS) system. The evolving payment mechanism should reflect collaboration between surgeon and system goals. Our aim was to model and perform simulation of a GP system for hernia care and its impact on cost, revenue, and physician reimbursement in an integrated health care system.
The results of the 2006 Watchful Waiting (WW) vs Repair of Inguinal Hernia in Minimally Symptomatic Men trial was used as a clinical model for the natural history and progression of inguinal hernia disease Simulations were built using 2009 financial and clinical data from the Cambridge Health Alliance to model costs and revenues in managing care for a 4-year cohort of inguinal hernia patients; FFS, FFS-WW, and the GP-WW were modeled. To build this GP model, surgeons were paid a constant $500 per patient whether herniorrhaphy was performed or not.
Compared with the actual combined physician and hospital revenue under the current FFS model ($308,820), implementing the FFS-WW system for 4 years for 139 hernia patients decreased hospital and physician revenues by $93,846 and $19,308, respectively. This resulted in a total savings of $113,154 for the payors only. In contrast, when using WW methodology within a GP model, system savings of $69,174 were observed after 4 years, with preservation of physician and hospital income.
Collaboration to achieve shared savings can be accomplished by pooling physician and hospital revenue in order to meet the goals of all parties.
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ABSTRACT: Many men with inguinal hernia have minimal symptoms. Whether deferring surgical repair is a safe and acceptable option has not been assessed. To compare pain and the physical component score (PCS) of the Short Form-36 Version 2 survey at 2 years in men with minimally symptomatic inguinal hernias treated with watchful waiting or surgical repair. Randomized trial conducted January 1, 1999, through December 31, 2004, at 5 North American centers and enrolling 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years. Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; repair patients received standard open tension-free repair and were followed up at 3 and 6 months and annually. Pain and discomfort interfering with usual activities at 2 years and change in PCS from baseline to 2 years. Secondary outcomes were complications, patient-reported pain, functional status, activity levels, and satisfaction with care. Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1% vs 2.2%, respectively; P = .06 [corrected]); PCS (improvement over baseline, 0.29 points vs 0.13 points; P = .79). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17% assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over improved after repair. Occurrence of postoperative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. One watchful-waiting patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, with a frequency of 1.8/1000 patient-years inclusive of patients followed up for as long as 4.5 years. Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.Clinical Trials Registration ClinicalTrials.gov Identifier: NCT00263250.JAMA The Journal of the American Medical Association 02/2006; 295(3):285-92. DOI:10.1001/jama.295.3.285 · 30.39 Impact Factor
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ABSTRACT: Chronic pain is a severe complication of mesh-based inguinal hernia repair. Its perceived risk varies widely in the literature. The current objectives are to review the incidence, severity, and consequences of chronic pain and its etiologies. A multi-database systematic search was conducted for prospective trials on mesh-based inguinal hernia repair reporting the measurement and outcome of pain at least 3 months postoperatively with a minimum follow-up of 80%. After mesh-based inguinal hernia repair, 11% of patients suffer chronic pain. More than a quarter of these patients have moderate to severe pain, mostly with a neuropathic origin. As a consequence of chronic pain, almost one third of patients have limitations in daily leisure activities. Chronic pain is less frequent after endoscopic repair and with the use of a light-weighted mesh.American journal of surgery 10/2007; 194(3):394-400. DOI:10.1016/j.amjsurg.2007.02.012 · 2.41 Impact Factor
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ABSTRACT: Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.Journal of the American College of Surgeons 11/2006; 203(4):458-68. DOI:10.1016/j.jamcollsurg.2006.06.010 · 4.45 Impact Factor