MD Anderson researchers found that the diagnostic phases are fairly inexpensive, with treatment accounting for most of the costs. Care bundles are now being rolled out; surgery alone in the lowest-cost bundle, for example, and surgery with reconstruction plus radiation and chemoradiation therapy in the most expensive bundle. Cases involving fewer than two co-morbidities are priced lower than those with two or more, based on MD Anderson findings that two or more co-morbidities typically start to significantly drive up costs. Outcomes, from survival to return to normal activities to readmissions, are also tracked.
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March 2016The new system is approximately halfway through its introduction, said Randal Weber, MD. “Financially it’s performing well,” he added. “I think we look at our risk and we put in appropriate stop losses to protect the margin, but we still have a way to go to get to the end of this journey.”
Accountability
Emily Boss, MD, MPH, director of pediatric surgical quality and safety at Johns Hopkins Bloomberg Children’s Center in Baltimore, said that the nation is more suspicious than ever that physicians might be making decisions based on finances and not on evidence-based medicine, and that physicians have to step up to show they are accountable.
“You might read The Laryngoscope, but most of the country is reading Reader’s Digest or Time magazine—people are paying attention to what we’re doing,” she said. “We need to show the public and our patients that we’re operating on them the right way, for the right reasons, using the best available evidence.”
Changes toward policy in value-based medicine is happening more slowly in pediatrics than in the rest of medicine, but they are coming, she said. One key example, she added, is the imminent application of pediatric HCAHPS patient-experience scores to value-based payment formulas for hospitals.
But some smaller, value-oriented changes are already underway. In response to a 2014 study finding a high rate of morbidity in tracheostomy cases, data on eight specific variables related to tracheostomy will now be collected at 81 institutions participating in the pediatric National Surgical Quality Improvement Program (JAMA Otolaryngol Head Neck Surg. 2014;140:1019-10126). The data will reflect variables such as post-operative chest X-rays and how placement of the tracheotomy is determined. The information could help lead to better utilization of procedures and tests.
Dr. Boss also pointed to the growing attention to the wildly varying rates of tonsillectomy among different regions of the United States—disparities that are not explained away by insurance status or race (J Pediatr. 2012;160:814-819.) She said there is little evidence suggesting that tonsillectomy is superior to watchful waiting for some children, and that physicians should learn the preferences and values of their patients when determining whether elective surgery is appropriate. “Value in pediatrics is an evolving concept,” she said. “But it is real and present and we need to be sitting at the table as we’re defining value for our specialty.”