|Complex Care For Obese Could Cut Into Doctor Incentives
P4P reimbursement of surgeons, intended to reward
doctors and hospitals for good patient outcomes, may instead be
creating financial incentives for discriminating against obese
patients. This population is much more likely to suffer expensive
complications after even the most routine surgeries, according to new
Johns Hopkins research.
Medicare and Medicaid, for example, are increasingly
using P4P formulas to cut doctor’s pay when their patients
develop infections after surgery. Obese patients are at significantly
greater risk of complications — notably surgical site infections
— following appendectomy and gallbladder removal surgery than
non-obese patients. They also cost thousands more dollars to treat than
"This is a government policy that promotes patient
selection and discrimination," said Dr. Martin A. Makary, associate
professor of surgery and health policy at the Johns Hopkins University
School of Medicine, and the study’s leader. "The policy
incentivizes doctors to pass on, stall or delay treatment of obese
patients, many of whom are minorities."
Makary suggests that the potential discrimination will
disproportionately affect African-Americans whose rates of obesity are
higher than in the white population.
He said hospitals and doctors should be held responsible
for preventing surgical complications but any P4P system needs to look
beyond complication rates and take into account the increased risks and
costs known to be associated with obesity.
Makary and his colleagues examined insurance claims for
35,096 patients who underwent gallbladder removal and 6,854 patients
who underwent appendectomy from 2002 to 2008. They compared 30-day
complications as well as total direct medical costs following surgery
for obese and non-obese patients.
They found that obese patients were 27 percent more
likely than non-obese patients to have complications following
gallbladder surgery and 11 percent more likely to have complications
following an appendectomy. These complications mean obese patients end
up costing more to treat, with median total inpatient costs for basic
gallbladder removal $2,978 higher for obese patients, and $1,621 higher
for obese patients who had an appendectomy.
Obese patients undergoing an appendectomy had longer
hospital stays and higher rates of reoperation, infection and
hemorrhage than non-obese patients, the researchers found. Obese
patients who had their gallbladders removed saw higher rates of blood
clots, reoperation and infection.
Measuring a patient’s waist circumference may be
more effective in predicting surgical outcomes than the more
traditional body mass index measure, said Dr. Christopher C. Thompson,
of Brigham & Women’s Hospital.
"Doctors have long been aware of the toll that obesity
takes on the body," Thompson added. New "studies help us understand the
specific ramifications of childhood and adult obesity and the increased
risk that obesity poses when considering surgical outcomes."
Address: Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205-2196; (410) 955-5000, www.hopkinsmedicine.org.