title: Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications.
abstract: BACKGROUND
  Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications.
  
  
  METHODS
  Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed.
  
  
  RESULTS
  A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients.
  
  
  CONCLUSIONS
  CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.
authors.affiliation: Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Malcolm H
authors.initials: MH
authors.lastname: Squires
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Staley
authors.forename: William
authors.initials: W
authors.lastname: Knechtle
authors.forename: Joshua H
authors.initials: JH
authors.lastname: Winer
authors.forename: Maria C
authors.initials: MC
authors.lastname: Russell
authors.forename: Sebastian
authors.initials: S
authors.lastname: Perez
authors.forename: John F
authors.initials: JF
authors.lastname: Sweeney
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000191:economics* / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D010478:Chemotherapy, Cancer, Regional Perfusion; D003131:Combined Modality Therapy; D065426:Cytoreduction Surgical Procedures / Q000191:economics*; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs; D006801:Humans; D006979:Hyperthermia, Induced / Q000191:economics*; D007902:Length of Stay; D008297:Male; D006278:Medicare; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000191:economics* / Q000473:pathology / Q000628:therapy; D010534:Peritoneal Neoplasms / Q000191:economics* / Q000556:secondary / Q000628:therapy; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D014481:United States