title: Cost of practice in a tertiary/quaternary referral center: is it sustainable?
abstract: BACKGROUND
  Third-party payers are moving toward a bundled care payment system. This means that there will need to be a warranty cost of care-where the cost of complexity and complication rates is built into the bundled payment. The theoretical benefit of this system is that providers with lower complication rates will be able to provide care with lower warranty costs and lower overall costs. This may also result in referring riskier patients to tertiary or quaternary referral centers. Unless the payment model truly covers the higher cost of managing such referred cases, the economic risk may be unsustainable for these centers.
  
  
  METHODS
  We took the last seven patients that were referred by other surgeons as "too high risk" for colectomy at other centers. A contribution margin was calculated using standard Medicare reimbursement rates at our institution and cost of care based on our administrative database. We then recalculated a contribution margin assuming a 3 % reduction in payment for a higher than average readmission rate, like that which will take effect in 2014. Finally, we took into account the cost of any readmissions.
  
  
  RESULTS
  Seven patients with diagnosis related group (DRG) 330 were reviewed with an average age of 66.8 ± 16 years, American Society of Anesthesiologists score 2.3 ± 1.0, body mass index 31.6 ± 9.8 kg/m(2) (range 22-51 kg/m(2)). There was a 57 % readmission rate, 29 % reoperation rate, 10.8 ± 7.7 day average initial length of stay with 14 ± 8.6 day average readmission length of stay. Forty-two percent were discharged to a location other than home. Seventy-one percent of these patients had Medicare insurance. The case mix index was 2.45. Average reimbursement for DRG 330 was $17,084 (based on Medicare data) for our facility in 2012, with the national average being $12,520. The total contribution margin among all cases collectively was -$19,122 ± 13,285 (average per patient -$2,731, range -$21,905-$12,029). Assuming a 3 % reimbursement reduction made the overall contribution margin -$22,122 ± 13,285 (average -$3,244). Including the cost of readmission in the variable cost made the contribution margin -$115,741 ± 16,023 (average -$16,534).
  
  
  CONCLUSIONS
  Care of high-risk patients at tertiary and quaternary referral centers is a very expensive proposition and can lead to financial ruin under the current reimbursement system.
authors.affiliation: Keck School of Medicine of the University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA, kyle.cologne@med.usc.edu.
authors.forename: K G
authors.initials: KG
authors.lastname: Cologne
authors.forename: G S
authors.initials: GS
authors.lastname: Hwang
authors.forename: A J
authors.initials: AJ
authors.lastname: Senagore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000191:economics / Q000628:therapy; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000191:economics*; D014481:United States