Return on Investment for Quality Improvement Collaboratives in Surgery

摘要： 受患者结局的广泛变化的激励，支付方实施了广泛的 旨在提高外科护理质量的举措。常见的战略包括： 卓越计划，引导患者前往可能具有上级结果和付费的医院 绩效计划，奖励医院遵守有针对性的护理流程。 最近，几个大的付款人已经开始资助国家或地区一级的质量改进（QI） 合作者虽然它们的细节各不相同，但这些努力通常涉及收集详细的临床数据 关于过程和结果，对提供者绩效的定期反馈， 质量改进机制。这些大型QI合作的早期结果表明， 有可能大大改善患者的治疗效果。尽管如此，广泛传播这一模式 由于与数据收集和方案协调相关的高成本， 每名病人50元至200元不等。 然而，许多人认为，与质量改进相关的节省可能会超过抵消这些费用。 成本据估计，手术并发症使平均支付的费用增加了11，000美元以上。 住院外科手术，其中大部分是转嫁给付款人。医院内差异很大 付款还意味着储蓄的机会。根据我们的试点研究， 密歇根州的一个大支付者，CABG和其他常见程序的平均总支付额各不相同 在考虑到合同价格差异后，各医院的费用超过5,000美元。大 这一变化的比例是由于非捆绑专业服务的差异， 指数入院率和30天再入院率。如果这种变化只能减少 适度地，质量改进不仅可以弥补成本，而且还可以大大减少 手术护理的总费用。 在探索大型QI合作在外科手术中的财务影响时，我们将研究来自以下方面的数据： 密歇根州蓝十字和蓝盾（BCBSM）的价值合作伙伴计划， 这是迄今为止最雄心勃勃的计划。这项计划涉及全州40多家医院， 每年招收近5万名患者，每年的管理费用超过1 000万美元。其 临床范围广泛，包括减肥、心脏、普通和血管外科，以及 经皮冠状动脉和外周动脉介入治疗，从而为 研究质量改进与成本之间的关系。

ABSTRACT: Motivated by wide variation in patient outcomes, payers have implemented a broad range of initiatives aimed at improving the quality of surgical care. Common strategies include centers of excellence programs that steer patients to hospitals likely to have superior outcomes and pay-for- performance plans, which reward hospitals for compliance with targeted processes of care. Recently, several large payers have begun funding state- or regional level quality improvement (QI) collaboratives. While their details vary, these efforts generally involve collecting detailed clinical data regarding process and outcomes, regular feedback on provider performance, and explicit mechanisms for quality improvement. Early results from these large QI collaboratives indicate their potential to substantially improve patient outcomes. Nonetheless, wide dissemination of this model remains limited due to the high costs associated with data collection and program coordination which range from $50 to $200 per patient. However, many believe that savings associated with quality improvement may more than offset such costs. By some estimates, surgical complications add over $11,000 to the average payments for inpatient surgical procedures, most of which is passed on to payers. Wide variation in hospital payments further suggests opportunities for savings. Based on our pilot studies using claims from one large payer in Michigan, average total payments for CABG and other common procedures vary by more than $5,000 across hospitals, after accounting for contractual price differences. A large proportion of this variation is attributable to differences in non-bundled specialty services during the index admission and in 30-day readmission rates. If such variation could be reduced only moderately, quality improvement would not only cover its costs, but also substantially reduce the overall costs of surgical care. In exploring the financial implications of large QI collaboratives in surgery, we will examine data from the Value Partnership Program of Blue Cross and Blue Shield of Michigan (BCBSM), the most ambitious program of its type to date. This program involves more than 40 hospitals statewide, enrolls almost 50,000 patients annually, and costs over $10 million each year to administer. Its clinical scope is broad, including bariatric, cardiac, general, and vascular surgery, as well as percutaneous coronary and peripheral arterial interventions, thus providing a rich substrate for examining the relationship between quality improvement and costs.