Review articleWill cost transparency in the operating theatre cause surgeons to change their practice?
Introduction
Over the past three decades, health care costs have risen exponentially and as a result continue to consume high percentages of gross domestic product (GDP) in many countries [1], [2]. Although regulatory bodies in many countries have tried to limit health care spending on treatments with a high cost to benefit ratio (cost/QALY), the true driver of medical expenditure likely occurs by decisions made at the bedside [3], [4], [5], [6]. Cost estimation strategies have taken both, “top-down” and, “bottom-up,” approaches with top down approaches dominating with most coverage decisions made by national institutes or large insurance companies [7]. Bottom-up approaches for cost estimation have several advantages including better granularity, transparency and versatility but there is a paucity of evidence evaluating actual bottom-up cost saving strategies and their impact on global costs.
When confronted with cost decision making at the patient level, physicians are often left in a very difficult place, both ethically and practically. For any given condition, there commonly exists a variety of possible treatments and although cost-effective information may exist for each, financial considerations are not generally the main driver of physician decisions. Many health care workers would argue that cost should not enter the decision making process at all; “the right treatment for the patient no matter the cost” [8]. Many physicians feel that they should make the best treatment choices and the decisions of coverage/cost should stay with policy makers [9]. This opinion has begun to change over the past decade, where many physicians now argue that cost should be a consideration in treatment decisions but there is limited evidence that this occurs practically. Physicians will alter their decision making if patients cannot explicitly afford certain treatments, but this may be the only scenario in which cost affects decision making [3], [10], [11], [12]. When an insurance provider or health authority cover numerous treatment options with varying costs, physicians will rarely consider costs [13]. Moreover, physicians are less likely to actually know the costs of different treatments in these scenarios [14], [15].
Price sensitivity is an economic term for how much demand changes relative to price of a certain product or new technology [16]. Technological advances in surgical devices or instruments will often boast more user friendly properties, purport technical advantages from previous versions or reduce time in the operating theater. Often, the price increase may be greater than the proposed advantages. Rarely is surgeon remuneration tied to the choice of implants and this creates a relative insensitivity to the key decision makers or users of instrumentation.
The volume and cost of spinal fusion procedures have increased along with advancements in instrumentation. With rapid innovation, spine surgeons have kept up with the application of the technology but have rarely considered the changing cost/benefit ratio [15], [17], [18]. Further, it is not known whether surgeons would change their choice of implant or fusion device if they were aware of significant cost variation from one treatment to the another. Many facilities deal with single vendors in order to take advantage of larger bulk pricing arrangements and this often leads to a lack of transparency in costs due to confidential price negotiation. Transparency in price is one of the key underpinnings of optimal supply and demand or marginal cost/marginal benefit relationships in free markets [19]. When there is little knowledge of price, it is extremely difficult for surgeons to make value based care decisions.
The global cost of spinal instrumentation is a small part of the overall cost of care for patients. There are estimates demonstrating that this can vary from 2 to 20% depending on the size and complexity of the treatment facility [20], [21]. There have been previous efforts to make surgeons aware of the costs of implants and/or the associated costs with surgery in an effort to decrease costs. These previous attempts have focused mostly on decreasing waste and creating leaner processes to improve flow [22], [23], [24]. There are few studies that evaluate whether surgeons change instrumentation strategies once they are aware of the costs of certain adjuncts and further whether these decisions will have any impact on overall costs for an institution [22]. The purpose of this study was to determine whether spine surgical procedural expenses change once physicians are aware of the costs for surgical implants and the total associated costs with the procedure.
Section snippets
Methods
Case cost data was collected prospectively from five orthopedic and neurological surgeons at a medium sized academic institution over a 10-month period (August 2016–June 2017). An initial 5-month period where surgeons were not aware of the current costs of surgical implants, hemostatic agents or bone graft substitutes/stimulants was followed by an un-blinding process where surgeons were given detailed cost data in the operating theater.
Patient inclusion criteria were (1) surgical indication for
Results
There were 46 consecutive patients with complete cost data in the pre-blind patient groups and 34 patients in the post-blind group. There were three re-operations in the pre-blinding group (medial pedicle screw irritating nerve root, irrigation and debridement for deep infection and wound dehiscence) and one re-operation in the post-blind group for a post-operative wound infection requiring irrigation and debridement. There were six patients lost to follow-up in the pre-blind group and two
Discussion
Price transparency is critical for making value based care decisions. Although the theory primarily applies to ideal free market scenarios, price transparency allows the primary decision makers of treatment to choose certain options more wisely. The results of this study demonstrate that there is a price signal that does have an impact on surgeon choice of implant.
The price difference in anterior cervical procedures was the greatest from the outset given the most expensive and least expensive
Limitations
Although the study demonstrates good internal validity with a robust bottom-up case costing methodology, the external validity is likely poor. The setting was a single centre in a single payer health-care system with two equipment vendors engaged in a sales contract with the hospital. Although transparency in cost is critical to optimize marginal benefit and marginal cost relationships, none of the other principles for efficient resource utilization are met. Without multiple vendors and
Conclusion
Increasing the transparency of cost of implants in the operating theater can lead to significant cost savings per surgical case, however, overall costs are not impacted by these initial cost savings. The findings of this study suggest that efficiency or patient flow targets may render greater savings to the overall cost of care rather than altering surgical implant choices or restricting the use of certain implants based on cost. Although there were no significant differences when comparing
Acknowledgement
The authors would like to thank the nursing staff at the Halifax Infirmary for all of their help with data collection in the operating room and Madison Stevens for all of her help with the data compilation.
References (31)
- et al.
Uncovering waste in US healthcare: evidence from ambulance referral patterns
J Health Econ
(2017) Cost-of-illness analysis
Health Policy
(2006)- et al.
Projecting long term medical spending growth
J. Health Econ
(2008) - et al.
Intra-operative waste in spine surgery: incidence, cost and effectiveness of an awareness program
Spine J
(2011) - et al.
Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery
Ann Thoracic Surg
(1997) - et al.
American health care paradox-high spending on health care and poor health
QJM
(2017) Rationing health care at the bedside
NYUL Rev
(1994)Managed care at the bedside: how do we look in the moral mirror?
Kennedy Inst Ethics J
(1997)- et al.
Equivalence of two healthcare costing methods: bottom-up and top-down
Health Econ
(2009) - Tan SS, Rutten FFH, Van Ineveld BM, Redekop WK, Roijen LH-V. Comparing methodologies for the cost estimation of...
The doctor's master
N Engl J Med
Clinicians and the economic evaluation of health
Salud Pública de México. Instituto Nacional de Salud Pública
The impact of socioeconomic status on the utilization of spinal imaging
Neurosurgery.
Influence of patients' socioeconomic status on clinical management decisions: a qualitative study
Ann Fam Med. American Academy of Family Physicians
Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice
J R Soc Med
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