Presented by: Hannah Kay MD
University of North Carolina at Chapel Hill

Introduction

Bundled payments are value-based reimbursement models that link payments to providers for episodes of care related to inpatient admissions for certain conditions. What remains a limitation of episode-based payments, however, is their inability to account for health care expenditures that may accrue prior to the inciting inpatient admission. Renal colic is uniquely suited to evaluate the association between pre- and post-operative events given high levels of variation in the timing and type of treatment. The objective of this study is to better understand how pre-operative costs may relate to operative and post-operative costs for a renal colic episode.

Materials

Using 2018 all-payer claims data from the Healthcare Cost and Utilization Project, we identified individuals in Florida, New York, Wisconsin, and Maryland who had a renal colic diagnosis, a subsequent definitive surgical episode after diagnosis, and a post-operative acute care encounter within 90 days of surgery. We categorized individuals into quartiles based on incurred costs during the pre-operative, operative, and post-operative periods and plotted the number of individuals in each quartile across the care time horizon using a Sankey diagram. Ordered logistic and linear regression were utilized to identify predictors of episode-related costs.

Results

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A total of 2,736 individuals met inclusion criteria during the study period. Among individuals in the highest pre-op cost quartile, 42% (n=288) remained in the two highest post-op cost quartiles. In multivariable analyses higher pre-operative costs predicted experiencing higher post-operative costs (OR 1.19, 95% CI 1.11-1.27; P<0.001). Drivers of higher pre-operative cost included delays in surgery (OR 1.85, 95% CI 1.69-2.01; P<0.001) and Medicaid vs. private insurance (OR 1.11, 95% CI1.03-1.20; P=0.007).

Conclusion

Our findings suggest that pre-operative spending influences post-operative expenditures for an episode of renal colic, and accounting for this relationship may help inform future iterations of surgical payment bundles.

Funding

American Urological Association Research Scholars Grant

Lead Authors

Matthew E. Nielsen, MD, MS, FACS
University of North Carolina at Chapel Hill

Charles D. Scales, MD, MSHS, FACS
Duke University

David F. Friedlander, MD, MPH
University of North Carolina at Chapel Hill