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EVALUATING OUTPATIENT VERSUS INPATIENT COSTS IN ENDOPHTHALMITIS MANAGEMENT

DESTRY J. SULKES, MD, MBA, INGRID U. SCOTT, MD, MPH, HARRY W. FLYNN, JR., MD, WILLIAM J. FEUER, MS
Purpose: To assess the cost savings that would result from 1) implementing the treatment guidelines of the Endophthalmitis Vitrectomy Study (EVS) and 2) performing procedures on an outpatient rather than an inpatient basis, and to compare the savings to the cost of conducting the EVS. Methods: The coding algorithms for four endophthalmitis treatment groups were obtained from Patient Financial Services at the Anne Bates Leach Eye Hospital (ABLEH) and national Medicare averages were consulted for reimbursements in 2000 dollars. The four groups were: 1) inpatient pars plana vitrectomy (PPV) with intravenous antibiotics; 2) outpatient PPV; 3) inpatient vitreous tap with intravenous antibiotics; and 4) outpatient vitreous tap. Physician reimbursements were calculated using International Classication of Diseases9 (ICD-9) diagnoses and Current Procedural Terminology (CPT) codes. Facility reimbursements were calculated using ICD-9 diagnoses and Diagnosis-Related Group codes for inpatient procedures versus Ambulatory Payment Classication codes for outpatient procedures. The annual savings in reimbursements were estimated for a range of annual incidence rates of endophthalmitis assuming ABLEH nancial data across all patients in the United States, and the savings into the future as well as the total expenses of conducting the EVS from 1989 to 1995 were summed in 2000 dollars using a net present value analysis based on the Bureau of Labor Statistics consumer price indices. Results: Facility reimbursements are signicantly higher for procedures performed on an inpatient compared to an outpatient basis (P 0.001). Treating endophthalmitis according to the EVS guidelines on an outpatient basis would be associated with an estimated $1.5 to $7.8 million reduction in reimbursements per year. The cost of the EVS in 2000 dollars was $4.0 million. Conclusions: Implementing the treatment guidelines of the EVS on an outpatient basis may result in signicant cost savingssavings that may cover the entire cost of the EVS in 3 years. RETINA 22:747751, 2002

he Endophthalmitis Vitrectomy Study (EVS), a multicenter clinical trial sponsored by the National Eye Institute, compared immediate pars plana
From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida. Supported in part by Research to Prevent Blindness, Inc., New York, New York. Reprint requests: Ingrid U. Scott, MD, MPH, Bascom Palmer Eye Institute, PO Box 016880 (D-880), Miami, FL 33101; e-mail: iscott@bpei.med.miami.edu

vitrectomy (PPV) to immediate vitreous tap, and intravenous antibiotics to no intravenous antibiotics, for the treatment of acute-onset endophthalmitis following cataract surgery or secondary intraocular lens implantation.1,2 For patients presenting with light perception only vision (26.2% of EVS patients), immediate PPV was associated with the greatest clinical benet. For patients presenting with hand motion or better vision (73.8%), the immediate PPV group and

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Fig. 1. Flow chart of the coding process.

the immediate vitreous tap group had similar visual outcomes. The administration of intravenous antibiotics was not signicantly associated with visual outcome. Guidelines from the EVS are commonly employed in clinical practice. Wisniewski and colleagues from the EVS investigated hospital charges related to the treatment of endophthalmitis and concluded that implementing the guidelines of the EVS (i.e., ceasing the administration of intravenous antibiotics and decreasing the number of vitrectomies) would result in a national reduction of hospital charges of $4.3 to $30.3 million, depending on the incidence of endophthalmitis and the pre-EVS patterns of treatment.3 Because the EVS was not designed to gather economic data, the study does not provide data on physician and outpatient procedure charges or reimbursements (the monies paid by insurers to facilities and physicians). In this era of managed care and cost concerns, it is important to obtain specic data on reimbursement savings rather than hospital charge savings because charges may be quite different from reimbursements. The current study was performed to investigate changes in total facility/physician reimbursements that would result from implementing the EVS guidelines on an outpatient basis, and to compare the savings to the cost of conducting the EVS.

Methods The coding algorithms for four different treatments of infectious endophthalmitis following cataract surgery were obtained from the Patient Financial Services Department at the Anne Bates Leach Eye Hospital, University of Miami School of Medicine. The reimbursements were obtained from national Medicare averages. All calculations were made using 2000 dollars. A ow chart (Figure 1) was developed that outlines the coding process for each of the following treatments: 1) inpatient PPV with intravenous antibiotics; 2) outpatient PPV; 3) inpatient vitreous tap with intravenous antibiotics; and 4) outpatient vitreous tap. The diagnosis code 360.0, purulent endophthalmitis, was obtained from the International Classication of Diseases9, the list of diagnosis codes approved by the Health Care Financing Administration (HCFA).4 The treatment codes for PPV and vitreous tap were obtained from the Current Procedural Terminology 2000 (CPT), the American Medical Association sponsored list of possible procedures.5 Medicare Part B physician reimbursements were obtained using scal year 2000 data on national averages.6 Inpatient reimbursements were obtained using Diagnosis-Related Groups2000 (DRG), the list created by HCFA of 497 different Medicare reimbursement levels based on average treatment costs.7 Outpatient reimbursements were obtained using Ambulatory Surgical Center

EVALUATING OUTPATIENT VS INPATIENT COSTS SULKES ET AL Table 1. Inpatient and Outpatient Financial Data Reimbursement, $US Treatment Group 1 2 3 4 Inpatient PPV (n 24) Outpatient PPV (n 199) Inpatient Tap (n 9) Outpatient Tap (n 73) Facility 2,840.15 1,646.62 2,840.15 1,646.62 Physician 867.75 867.75 529.17 529.17

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Total 3,707.90 2,514.37 3,369.32 2,175.79

Note: Data are from the Anne Bates Leach Eye Hospital Patient Financial Services, International Classication of Diseases9th ed., Diagnostic Related Groups, Current Procedural Terminology, and Ambulatory Payment Classications.

(ASC) payment rates and Ambulatory Payment Classications2000 (APC), the list created by HCFA of nine different Medicare reimbursement levels based on average treatment costs.8 Facility and physician reimbursements for each of the four treatments were calculated (Table 1). Next, three different pre-EVS treatment patterns and the estimated annual number of endophthalmitis cases were employed to calculate total reimbursements on an inpatient basis (Table 2). Given the approximately 1.5 million cataract surgeries performed per year in the United States,9 and the reported 0.1% to 0.4% incidence of postoperative endophthalmitis,10 12 the estimated range of endophthalmitis cases in the United States is 1,350 to 5,400. Finally, facility and physician reimbursements were calculated assuming that 1) 26.2% of patients present with light perception vision or worse1 and would receive immediate PPV, 2) procedures were performed on an outpatient basis, and 3) there was no administration of intravenous antibiotics (Table 3). Reimbursements associated with various pre-EVS treatment patterns (from all patients treated with PPV to all patients treated with vitreous tap) and treatment using EVS guidelines on an outpatient basis were compared. The direct and indirect expenses of the EVS from 1989 to 1995 were provided by the National Eye Institute. These expenses, as well as the annual sav-

ings that may be realized from implementing EVS guidelines, were transformed into one-time gures in 2000 dollars by performing a net present value analysis based on discount rates calculated using the consumer price indices (CPI) for each year as provided by the Bureau of Labor Statistics13 (Table 4). The savings were projected from year 2000 assuming a constant average rate of CPI ination of 4.75%, the average from 1989 to 1995, a rate that is greater than the present rate in the United States (1.6% over the 12 months ending in April 2002) and will lead to a conservative savings estimate.13 Physician and facility reimbursements were xed and not subject to variability; therefore, statistical analysis in this study was limited. Results Physician reimbursements were the same for a given procedure whether the procedure was performed on an inpatient or an outpatient basis (Table 1). In the United States, the average physician reimbursement was $867.75 for PPV and $529.17 for vitreous tap. Facility reimbursements were different depending on whether the procedure was performed on an inpatient or an outpatient basis; however, the reimbursement levels were the same for PPV and vitreous tap. Both PPV and vitreous tap, when performed on an

Table 2. Pre-EVS Inpatient and Post-EVS Outpatient Financial Data: Total Charges Using Pre-EVS Treatments on an Inpatient Basis Annual of Cases Minimum* 1350 1350 1350 1350 Maximum 5400 5400 5400 5400 Treatment Pre-EVS, % PPV 100 50 11.4 0 Tap 0 50 88.6 100 Total Facility Physician Reimbursement Minimum 5,005,665 4,777,124 4,600,689 4,548,582 Maximum 20,022,660 19,108,494 18,402,758 18,194,328

* Based on an incidence of 0.1% per Dr. Aabergs 10-year study.9 Based on an incidence of 0.4% per Dr. Javitts survey of endophthalmitis causes.10 EVS, Endophthalmitis Vitrectomy Study; PPV, pars plana vitrectomy.

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Table 3. Pre-EVS Inpatient and Post-EVS Outpatient Financial Data: Total Changes Using EVS Guidelines and Treatments on an Outpatient Basis Annual No. of Cases Minimum 1350 Maximum 5400 EVS Guidelines,% PPV 26.2 Tap 73.8 Total Facility Minimum 3,057,072 Maximum 12,228,289 Reimbursement Savings, US$* Minimum 1,948,593 1,720,051 1,543,617 1,491,510 Maximum 7,794,371 6,880,205 6,174,469 5,966,039

Based on EVS incidence data, treatment recommendations, and ABLEHs charge and reimbursement data for hospital versus outpatient treatment, annual national charge savings are $7.1 to 30.3M and reimbursement savings are $1.5 to 7.9M. * Based on Section A (range of pre-EVS treatments) minus Section B (actual EVS guidelines treatments) calculation. EVS, Endophthalmitis Vitrectomy Study.

inpatient basis, were reimbursed at the same level: $2,840. This is due to the coding intricacies of the DRG system, which is dependent on the diagnosis rather than the specic treatment. Similarly, the ASC coding mechanism, which in years before 2000 had provided different reimbursements for the two procedures when performed on an outpatient basis, has been updated to encourage diagnostic rather than treatmentbased reimbursement policies, and also reimburses the two outpatient procedures at the same level: $1,647. Treating suspected infectious endophthalmitis on an outpatient basis would be associated with a national decrease in total reimbursement of an estimated $1.5 to $7.8 million. The savings are a consequence of decreased reimbursements when switching from inpatient to outpatient treatment. In addition, fewer vitrectomies might be performed in institutions where treatment patterns currently favor PPV for patients with endophthalmitis with hand motion or better vision. The total cost of the EVS, conducted between 1990 and 1995 at 24 clinical centers, was $4.0 million in 2000 dollars. The lowest projected savings that would result from implementing the EVS guidelines using the average

4.75% CPI annual change, over a period of 3 years, is $4.3 million dollars. Discussion The current study is limited because Medicare regulations and reimbursement levels are constantly changing. It is also important to note that this study does not assess whether the move from inpatient to outpatient treatment is associated with a higher rate of complications or need for repeat procedures. Finally, the current study does not assess differences in patients quality of life associated with the various treatment patterns, nor does the study assess the value that inpatient treatment provides to family members who are responsible for transporting and assisting the patients involved. Such values must be evaluated to provide an accurate understanding of the full differences between inpatient and outpatient treatments. Signicant health care cost savings may be realized by implementing the EVS guidelines on an outpatient basis. It is hoped that the efciency of the health care system will be evaluated with the goals of reducing costs while maintaining the highest standard of patient

Table 4. Total Cost of the Endophthalmitis Vitrectomy Study in 2000 Dollars Year Total Dollars Spent Average Annual CPI* 124 130.7 136.2 140.3 144.5 148.2 152.5 4.75 2000 Average CPI* 172.2 172.2 172.2 172.2 172.2 172.2 172.2 Change in CPI From Given Year to 2000; % 38.9 31.8 26.4 22.7 19.2 16.2 12.9 2000 Dollars 595,998 803,119 756,652 640,574 713,648 353,383 163,378 4,026,753
100, US All-City Average.

1989 364,328 1990 548,112 1991 556,656 1992 494,927 1993 576,845 1994 296,155 1995 142,273 Average Annual Change Total

* Consumer Price Indices (CPI) from the Bureau of Labor Statistics 19821984

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care. Inpatient endophthalmitis treatment is still considered when there is severe ocular or orbital pain, advanced concurrent systemic disease, poor patient compliance with medical therapy, or poor patient reliability for follow-up evaluations. However, treatment in an outpatient ambulatory surgical center has become increasingly prevalent in the United States. Given that $1.5 million is the lowest amount saved under all assumptions in the current study, it is interesting to note that the entire cost of the EVS, $4.0 million, would be entirely paid back in 3 years if the guidelines were adopted. Thus, the funding provided by the National Institutes of Health and the National Eye Institute in support of the EVS may result in a much larger payback to the nation in terms of saved medical costs. Key words: Endophthalmitis Vitrectomy Study, EVS, endophthalmitis. Acknowledgment
The authors thank Henaly Gonzalez, Vivian Passaro, and Johanna Delbusto, Patient Financial Services, Anne Bates Leach Eye Hospital; and Donald Everett, Rick Ferris, and John Whitaker, National Eye Institute.

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