Baker, Mary V.

AbstractObjectiveTo compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway.MethodsThe present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost‐to‐charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30.ResultsFor the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331–$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P = 0.754), 30‐day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P = 0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P = 0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001).ConclusionsDecreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

AbstractObjectiveTo assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy.MethodsRetrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair.ResultsPatients were subdivided into pre‐ERAS (G1, n = 128), post‐ERAS (G2, n = 83), and post‐ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0–2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20–75] vs. 67 [31–109], and 60 [30–122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001).ConclusionImplementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures.

IntroductionWe calculate the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, health care provider type, and number of office visits. Antenatal care is only one component of the global maternity bundle, which also includes intrapartum and postpartum care.MethodsTime for provision of low‐risk antenatal care was determined prospectively from a study of 133 low‐risk pregnant patients. Health care provider time cost was estimated using mean wages for obstetricians and midwives. Margins were estimated by subtracting cost of provider services and overhead for the antenatal component of maternity care from total Medicaid reimbursement for the pregnancy global package (CPT 59400) using 2015 dollars. The maternity bundle elements of routine prenatal laboratory tests, ultrasounds, intrapartum care, and postpartum care were not included in our analysis of cost components.ResultsPatients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 53.4% of revenue, practice margins varied by state from −$1067 to +$675, with a median of −$357. Median margins for midwifery care were +$15, with a range of −$579 to +$885. Margins were negative if overhead costs exceeded 33% of revenue for physician care and 55% of revenue for midwifery care.DiscussionIn many states, Medicaid reimbursement for the global maternity package is less than the actual cost of antenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care more cost‐effective.

INTRODUCTION: This study calculates the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, provider type, and number of office visits. Antenatal care is only one component of the global obstetric bundle, which also includes intrapartum and postpartum care. METHODS: Revenue was based on 2015 Medicaid reimbursement for the pregnancy global package (CPT 59400). All fifty states were represented. Provider time cost was estimated using mean wages for obstetricians and midwives, or using national mean wage data when state-specific data was unavailable. Staff time for provision of low risk prenatal care was determined prospectively from a study of 133 low risk patients. Sensitivity analysis was performed by varying overhead as a percentage of total revenue. Routine prenatal labs, ultrasounds, intrapartum care, and postpartum care were not included in our analysis. RESULTS: Patients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 40% of revenue, practice margins varied by state from -$1,061 to +$785, with a median of -$161. This does not include the cost of intrapartum or postpartum care. The median margin for antenatal care was negative if overhead exceeded 18% of revenue. CONCLUSION: In a majority of states, reimbursement for the global obstetric package reimbursed by Medicaid is less than the actual cost of prenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care cost-effective for obstetrics practices.