Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings

“As health care expenditures continue to increase, with surgery accounting for approximately one-third of all health care spending, there is a need to identify strategies to decrease expenditures without compromising care quality.

[..] the purpose of this study was to perform a population-based analysis of complication rates of minor hand procedures performed in different operative settings. In addition, we sought to investigate differences in total cost and OOP [out-of-pocket] spending across different operative settings.

[..] We performed a retrospective cohort study using data from the IBM MarketScan Research databases between 2009 and 2017. These databases contain information from more than 240 million patients enrolled in employer-sponsored health insurance from more than 350 payers nationwide and include longitudinal health care encounters, patient-level costs, and pharmaceutical data.

[..] we selected patients aged 18 years or older undergoing open carpal tunnel release, trigger finger release, excision of wrist ganglion cysts, or excision of hand masses. The procedures were chosen based on their low complexity and potential to be performed under local anesthesia in any operative setting (eg, hospital outpatient department [HOPD], ASC [ambulatory surgery center], and the office). Endoscopic carpal tunnel release was not included because it is not typically performed in all 3 operative settings under local anesthesia. [..] All patients included in the cohort had continuous enrollment in the database 6 months before the surgery and 3 months after the surgery to permit observation of comorbidities and postoperative complications. We excluded patients who had procedures performed during an inpatient hospital admission or claims for which the total payments as paid to the insurer were less than or equal to 0 or the out-of-pocket (OOP) expenses were less than 0.

[..] A total of 468,365 patients were included in our cohort between 2009 and 2017 with 296,378 women (63.3%) and 171,987 men (36.7%). The most common procedures performed were carpal tunnel release (252,524 [53.9%]), followed by trigger finger release (133,671 [28.5%]). [..] Procedures were most commonly performed in HOPDs (284,889 [60.8%]), followed by ASCs (158,659 [33.9%]), with few (24,817 [5.3%]) performed in an office setting (P < .001). Trigger finger releases (13,865 [10.4%]) and excision of small hand masses (6155 [13.5%]) were more likely to be performed in the office, compared with carpal tunnel release (4145 [1.6%]) or wrist ganglion cyst excision (652 [1.8%]) (P < .001).

[..] After controlling for patient characteristics, procedures performed in HOPDs and ASCs had greater odds of having a complication compared with the office setting (HOPD: OR, 1.32; 95% CI, 1.22-1.43 and ASC: OR, 1.24; 95% CI, 1.14-1.34).

[..] Procedures performed in the office were significantly less expensive for payers (median total payment for surgery: $764 in the office, $1341 in HOPDs, $1202 in ASCs, P < .001) and patients (median OOP expenses for surgery: $41 in the office, $76 in HOPDs, $99 in ASCs, P < .001). Moreover, the total payment for the surgical episode plus 90-day postoperative period was $2664 (interquartile range [IQR], $1370-$4861) for procedures performed in HOPDs, $2184 (IQR, $1316-$3880) in ASCs, and $1433 (IQR, $912-$2506) in the office (P < .001). For OOP expenses, procedures performed in HOPDs incurred $230 (IQR, $62-$575) for the surgical episode plus 90-day postoperative period, $248 (IQR, $72-$583) in ASCs, and $152 (IQR, $44-$413) in the office. In addition, patients having office-based procedures experienced less frequent postoperative emergency department visits compared with those from the other operative settings (85 [0.3%] in the office, 1916 [0.7%] in HOPDs, and 774 [0.5%] in ASCs, P < .001) and lower rates of rehospitalizations (543 [2.2%] in the office, 7965 [2.8%] in HOPDs, and 3769 [2.4%] in ASCs, P < .001).

Using multivariable regression models, we determined that patients who underwent surgery in an HOPD had approximately 145% of the estimated total payment of the surgical episode plus 90-day postoperative period compared with those from the office setting (cost ratio: 1.45; 95% CI, 1.43-1.46), which conferred an additional $1216 (95% CI, $1184-$1248). Similarly, surgical procedures performed in ASCs were approximately 126% of the estimated total payment of office procedures (cost ratio: 1.26; 95% CI, 1.25-1.27), corresponding to an added $709 (95% CI, $676-$741).

In the adjusted regression for OOP expenses, minor procedures performed in HOPDs were 129% (cost ratio: 1.29; 95% CI, 1.27-1.31) of the estimated OOP expenses of procedures performed in the office, which conferred an additional $115 in OOP expenses (95% CI, $109-$121). Procedures performed in ASCs were 135% (cost ratio: 1.35; 95% CI, 1.34-1.37) of the estimated OOP expenses of office procedures, leading to an extra $140 in OOP expenses (95% CI, $134-$146). Shifting ASC and HOPD procedures to the office could save patients an estimated $6 million annually during the study period in OOP expenses.

[..] Data from the Centers for Medicare & Medicaid Services have shown an increase in outpatient surgery from 2008 to 2010 with a transition to freestanding ASCs. Because of this transition and concerns about increased spending, the Centers for Medicare & Medicaid Services have enacted policies to curb ASC spending with mixed efficacy. In a study by Carey, HOPDs received lower payments for similar surgical procedures in areas with a high density of ASCs, suggesting an influence of ASCs on price negotiation. However, few studies have addressed the spending associated with procedures that can be performed in multiple operative settings, specifically the office setting. In a single-institution study by Rhee et al, performing minor hand procedures in the office saved approximately $393,100 compared with performing similar procedures in the operating room. Moreover, in a national study of carpal tunnel releases, the largest contributor to greater charges was operative setting, with HOPDs associated with a $500 higher charge than ASCs. However, the office setting was not included in this analysis. In our study, only 5.3% of minor procedures were performed in the office setting, but these office-based procedures were significantly less costly than those performed in other operative settings, highlighting the underuse of the office as an operative setting. Although the difference in cost associated with operative setting is not surprising, it raises the question as to why more minor procedures are not being transitioned to the office setting. Currently, payer and hospital incentives are lacking to encourage office-based procedures. In addition, there may be clinician-level barriers to performing surgery in the office, such as disruption of clinical workflow, need to secure and process surgical instruments, and lack of technical assistants.”

Full article, Billig JI, Nasser JS, Chen JS et al. JAMA Network Open 2020.10.13