title: A perverse quality incentive in surgery: implications of reimbursing surgeons less for doing laparoscopic surgery.
abstract: Surgery is one of the highest priced services in health care, and complications from surgery can be serious and costly. Recently, advances in surgical techniques have allowed surgeons to perform many common operations using minimally invasive methods that result in fewer complications. Despite this, the rates of open surgery remain high across multiple surgical disciplines.
  
  
  
  This is an expert commentary and review of the contemporary literature regarding minimally invasive surgery practices nationwide, the benefits of less invasive approaches, and how minimally invasive compared with open procedures are differentially reimbursed in the United States. We explore the incentive of the current surgeon reimbursement fee schedule and its potential implications.
  
  
  
  A surgeon's preference to perform minimally invasive compared with open surgery remains highly variable in the U.S., even after adjustment for patient comorbidities and surgical complexity. Nationwide administrative claims data across several surgical disciplines demonstrates that minimally invasive surgery utilization in place of open surgery is associated with reduced adverse events and cost savings. Reducing surgical complications by increasing adoption of minimally invasive operations has significant cost implications for health care. However, current U.S. payment structures may perversely incentivize open surgery and financially reward physicians who do not necessarily embrace newer or best minimally invasive surgery practices.
  
  
  
  Utilization of minimally invasive surgery varies considerably in the U.S., representing one of the greatest disparities in health care. Existing physician payment models must translate the growing body of research in surgical care into physician-level rewards for quality, including choice of operation. Promoting safe surgery should be an important component of a strong, value-based healthcare system. Resolving the potentially perverse incentives in paying for surgical approaches may help address disparities in surgical care, reduce the prevalent problem of variation, and help contain health care costs.
authors.affiliation: Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
authors.forename: Amanda N
authors.initials: AN
authors.lastname: Fader
authors.affiliation: Department of Surgery, Johns Hopkins Medicine, Baltimore, MD, USA.
authors.forename: Tim
authors.initials: T
authors.lastname: Xu
authors.affiliation: Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.|Department of Health Policy and Management, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Dunkin
authors.affiliation: Department of Surgery, Johns Hopkins Medicine, Baltimore, MD, USA. mmakary1@jhmi.edu.|Department of Surgery, Weill Cornell Medical College, New York City, NY, USA. mmakary1@jhmi.edu.|Surgery and Health Policy and Management, Johns Hopkins University School of Medicine, Halsted 610, 600 N. Wolfe St, Baltimore, MD, 21287, USA. mmakary1@jhmi.edu.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
mesh_terms: D017046:Cost Savings; D005245:Fee Schedules; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000191:economics / Q000379:methods; D009042:Motivation; D011183:Postoperative Complications / Q000453:epidemiology*; D012051:Reimbursement Mechanisms; D066231:Surgeons; D014481:United States
keywords: Incentives; Minimally invasive surgery; Quality; Reimbursement