SESSION TITLE: Disorders of the Pleura
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Wednesday, October 28, 2015 at 02:45 PM - 04:15 PM
PURPOSE: Malignant pleural effusions (MPEs) affect over 200,000 patients per year. Traditionally, thoracentesis has been part of a procedure-based model in an outpatient hospital facility, such as Interventional Radiology (IR) or Ultrasound (US), where pre-procedural coagulation is checked and post-procedural x-ray is performed. This model is often fragmented with treatment planning not determined by the proceduralist. We hypothesize that a program-based model, where a thoracentesis is performed in a clinic setting without additional investigations by a specialist responsible for the treatment plan, is more cost-effective care delivery in the era of Accountable Care Organizations (ACOs).
METHODS: The procedural model consists of laboratory panel, thoracentesis, and x-ray performed in an outpatient hospital facility. The facility cost of a thoracentesis (bundled laboratories and kit) and chest x-ray were based on geometric national mean cost data obtained from the 2015 Cost for Outpatient Services published by the Centers for Medicare and Medicaid Services (CMS). The physician procedure fee was based on an internal calculation: RVUs from the 2015 CMS Physician Fee Schedule multiplied by the $/RVU based on a Thoracic Surgery and Interventional Pulmonology practice normalized to the national average. The programmatic model consisted of a thoracentesis performed in an outpatient clinic by a specialist and a 25-minute office visit. The cost of the clinic procedure (physician fee bundled), and office visit were similarly based on our internal calculation. Payment data, for both models, was obtained from CMS using 2015 Hospital Outpatient Prospective Payment Rates and the 2015 Physician Fee Schedule.
RESULTS: The calculated loss between cost and payment is smaller in the procedural model, $128.25 vs $186.47, and thus favorable in a ‘fee-for-service’ model. However, the total cost to the facility is lower in the programmatic approach, $588.36 vs $793.67, and is more cost effective in ACO models.
CONCLUSIONS: Traditional ‘fee-for-service’ models benefit from a smaller margin between health care costs and insurance reimbursements, and thus the procedure-based model. In the era of ACOs, with the focus on cost and value of care, the clinic-based programmatic approach is lower cost.
CLINICAL IMPLICATIONS: The adoption of ACO models will require institutions to assume financial risk and implement value-based quality care pathways. The programmatic model is more cost-effective and best suited to this transformation in care delivery.
DISCLOSURE: The following authors have nothing to disclose: Candice Wilshire, Rob Ely, Joelle Fathi, Brian Louie, Ralph Aye, Alexander Farivar, Eric Vallieres, Jed Gorden
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