Big savings. Analyzing 321,956 adult patients who were insured through employer-sponsored health plans between 2000 and 2009, researchers compared outcomes during the period from 14 days before through 352 days after surgery on six types of treatments that both traditional open surgery and minimally invasive options.
The six types of surgery — coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization and aortic aneurysm repair — were chosen because they were among the most common for non-elderly adults during the 2000-2009 study period, says Andrew Epstein, PhD, the lead researcher for the JAMA study and an associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. It was also possible to distinguish between minimally invasive and traditional procedures in claims data for these six types of surgery, helping the study authors to more easily compare outcomes from both types of procedures.
Three of the six minimally invasive options were significantly cheaper than their traditional counterparts, sometimes by more than $30,000. Four of the minimally invasive options resulted in significantly fewer missed days of work, and none resulted in more lost days of work, according to the study.
Applying the study results to all non-elderly adults with employer-sponsored health insurance nationwide, researchers claim minimally invasive surgeries saved group health plans $8.9 billion in 2009. And, because MIS patients lost fewer days of work, employers across the country could have recovered enough working days to total 53,134 standard 260-day working years. Using the 2009 national average wage of $40,712, that absenteeism represents the potential for $2.2 billion in savings.
Had every one of the six types of surgery across the country in 2009 been performed via minimally invasive means, researchers project the additional net savings through lower costs and fewer missed work days would be $3.1 billion, for a total of $14 billion saved.
Some disclaimers. There were some assumptions made to reach those numbers, which could have inflated them slightly, says Dr. Epstein says. For one, since the patients were all covered by employer health plans, the study assumes all of them were working in order to estimate how many fewer days they would miss from shorter recovery times attributed to minimally invasive surgery. In reality, some of those patients may have been covered by their spouse’s health plans and not working at all, Dr. Epstein says.
The study also assumes, as noted in the study, that all patients would be eligible candidates for minimally invasive procedures, says Cindy Grines, MD, vice president of the cardiovascular institute at the Detroit Medical Center and a professor of medicine at Wayne State University. In reality, although less-invasive angioplasty tends to have fewer complications than open bypass surgery, diabetic patients with multiple blockages have better results from bypass surgery, says Dr. Grines, who is also on the board of trustees for the Society of Cardiac Angiography and Interventions.
Still, the results clearly show the saving potential of minimally invasive procedures when clinically appropriate, Dr. Epstein says. Plus, Dr. Grines says these procedures are popular with her patients because they result in smaller or no scars and more comfortable recoveries.
Why not outpatient? Minimally invasive procedures are not new, Dr. Grines says, and have been increasing in popularity and effectiveness since the 1990s. Older physicians once leery of them have received training, and new physicians coming into the profession are well-prepared to perform them. Payors are especially fond of MIS because the procedures can be performed with much shorter hospital stays, less or no general anesthesia and often fewer complications requiring follow-up attention.
If some of these minimally invasive surgeries require so little time in the hospital for patients’ recovery, why not move them to the outpatient setting to save even more money for payors and providers engaged in shared-savings payment plans? For procedures where that would be feasible, Dr. Grines says the issue is in anti-kickback and Stark Law restrictions.
In the case of angioplasty, which allow patients to be discharged sometimes in as little as six to 12 hours after the procedure is performed, regulations specifically bar cardiologists from performing the procedures in outpatient facilities to ensure patients have a hospital’s back-up services in case of complications, and to prevent conflicts that could arise if a physician in a hospital refers a patient for angioplasty in an ambulatory surgery center in which they have ownership.
Dr. Grines says there have been recent efforts to change this in the interest of lower cost to patients. Under billing codes, patients can even stay overnight after the procedure and still be billed as outpatients, typically far more cost-effective than if they were categorized as inpatients. There’s evidence to suggest that with a longer history of better, less expensive outcomes, restrictions may loosen on the setting in which MIS can be performed.
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