The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency.

Background: Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood. Objective: To quantify the costs of inpatient and outpatient surgery in the Medicare population. Methods: We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008–2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpatient episode payments by surgical specialty. For inpatient episodes, we determined component payments related to the index hospitalization, readmissions, physician services, and postacute care. For outpatient episodes, we differentiated by the site of care (hospital outpatient department versus physician office versus ambulatory surgery center). We used linear regression to evaluate temporal trends in inpatient and outpatient surgical spending. Finally, we estimated the contribution of surgical care to overall Medicare expenditures. Results: Total Medicare payments for surgical care are substantial, representing 51% of Program spending in 2014. They declined modestly over the study period, from $133.1 billion in 2008 to $124.9 billion in 2014 (−6.2%, P = 0.085 for the temporal trend). While spending on inpatient surgery contributed the most to total surgical payments (69.4% in 2014), it declined over the study period, driven by decreases in index hospitalization (−16.7%, P = 0.002) and readmissions payments (−27.0%, P = 0.003). In contrast, spending on outpatient surgery increased by $8.5 billion (28.7%, P < 0.001). This increase was realized across all sites of care (hospital outpatient department: 36.6%, P < 0.001; physician office: 22.1%, P < 0.001; ambulatory surgery center: 36.6%, P < 0.001). Ophthalmology and hand surgery witnessed the greatest growth in surgical spending over the study period. Conclusions and Relevance: Surgical care accounts for half of all Medicare spending. Our findings not only highlight the magnitude of spending on surgery, but also the areas of greatest growth, which could be targeted by future payment reforms.

Importance Readmissions after surgery lead to poor patient outcomes and increased costs. The Hospital Readmission Reduction Program (HRRP) penalizes hospitals with excess readmissions after specified medical and surgical discharges. Objective To evaluate the effect of this policy on readmissions after major joint surgery (targeted) and procedures with historically high rates not under its purview (non-targeted). Design Using a 20% Medicare sample we performed a retrospective cohort study of patients undergoing one of five major surgeries between January 1, 2006 and November 30, 2014. Setting Population based analysis. Participants Our study included 507,663 patients with targeted (total hip arthroplasty, total knee arthroplasty) and 164,472 patients with non-targeted (abdominal aortic aneurysm repair, colectomy, lung resection) procedures performed at 2,773 hospitals. Exposure Implementation of the HRRP policy. Main Outcomes and Measures We calculated hospital level 30-day risk-adjusted rates of readmission and observation stays using multivariable logistic regression models. Changes in these rates were analyzed for three distinct time periods (Pre-policy (1/1/2006 to 6/30/2010), Performance (7/1/2010 to 6/30/2013), Penalty (7/1/13 to 11/30/14)) corresponding to the HRRP implementation timeline for major joint surgery, using interrupted time series. Results Readmissions for all procedures decreased significantly over the study period. Readmission rates after targeted procedures decreased faster during the Performance period (slope: −0.060, 95% CI: −0.079 to −0.041) compared to the Pre-policy period (slope: −0.012, 95% CI: −0.027 to 0.034, p <0.002). For non-targeted procedures, readmission rates were decreasing during the Pre-policy period (slope: −0.20, 95% CI: −0.24 to −0.16) but stabilized during the Performance period (slope: 0.0084, 95% CI: −0.049 to 0.066, p <0.001). Use of observation stays increased slightly, accounting for 11% of the decrease in readmissions. Conclusions The HRRP effectively decreased readmissions for targeted procedures. There were no associated spillover effects for common non-targeted procedures. A better understanding of differences in impact of the policy across medical and surgical discharges will be necessary to further enhance its effects and generalizability.

Background Abiraterone and enzalutamide are high‐cost oral therapies that increasingly are used to treat patients with advanced prostate cancer; these agents carry the potential for significant financial consequences to patients. In the current study, the authors investigated coping and material measures of the financial hardship of these therapies among patients with Medicare Part D coverage. Methods The authors performed a retrospective cohort study on a 20% sample of Medicare Part D enrollees who underwent treatment with abiraterone or enzalutamide between July 2013 and June 2015. The authors described the variability in adherence rates and out‐of‐pocket payments among hospital referral regions in the first 6 months of therapy and determined whether adherence and out‐of‐pocket payments were associated with patient factors and the socioeconomic characteristics of where a patient was treated. Results There were 4153 patients who filled abiraterone or enzalutamide prescriptions through Medicare Part D in 228 hospital referral regions. The mean adherence rate was 75%. The median monthly out‐of‐pocket payment for abiraterone and enzalutamide was $706 (range, $0‐$3505). After multilevel, multivariable adjustment for patient and regional factors, adherence was found to be lower in patients who were older (69% for patients aged ≥85 years vs 76% for patients aged <70 years; P < .01) and in those with low‐income subsidies (69% in those with a subsidy vs 76% in those without a subsidy; P < .01). Both Hispanic ethnicity and living in a hospital referral region with a higher percentage of Hispanic beneficiaries were found to be independently associated with higher out‐of‐pocket payments for abiraterone and enzalutamide. Conclusions There were substantial variations in the adherence rate and out‐of‐pocket payments among Medicare Part D beneficiaries who were prescribed abiraterone and enzalutamide. Sociodemographic patient and regional factors were found to be associated with both adherence and out‐of‐pocket payments.

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