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Home / News & IndustryManaged Care Insight and Analysis
Updated: January 11, 2011
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 the non-obese.

"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.


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