Survey-Based Reporting of Post-Operative Visits for Select Procedures with 10- or 90-Day Global Periods

Final Report

by Courtney A. Gidengil, Andrew W. Mulcahy, Ateev Mehrotra, Susan L. Lovejoy

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Research Questions

  1. What are the reported time and work associated with post-operative visits during the global period for three procedures: cataract surgery, hip arthroplasty, and complex wound repair?
  2. How do reported time and work vary by key characteristics, including procedure type, visit location, other procedures performed, whether the visit was expected, whether it was the first visit, and participation in an Accountable Care Organization?
  3. How much time is spent on post-operative visits as reported by physicians versus non-physicians, and how much is face-to-face versus non–face-to-face?
  4. How does the reported work performed compare with expected work based on the Physician Time File?

For many surgeries and procedures, Medicare and most other insurers cover a bundle of services, including post-operative visits, during the global period. As part of 2015 MACRA legislation, Congress mandated that the Centers for Medicare & Medicaid Services (CMS) collect data on the number and level of post-operative visits delivered in the global period to assess accuracy of payment. Among other efforts, CMS conducted a practitioner survey to assess the level of visits, using three procedures as proof of concept: cataract surgery, hip arthroplasty, and complex wound repair.

Using data reported via the survey, the authors found that reported physician time and work for cataract surgery and hip replacement post-operative visits were generally similar — but slightly less — than the levels expected based on the evaluation and management visits assumed to typically occur when valuing these procedures. Reported physician time and work for complex wound repair post-operative visits were higher than Physician Time File levels.

Based on experiences with various approaches to collecting data on the level of post-operative visits as well as the status quo, the authors suggest thinking of these data collection methods as a spectrum with both benefits and trade-offs. Given the strengths and weaknesses of these approaches, the authors recommend consideration of a claims-based approach coupled with information about the level of service or the use of G-codes. A survey instrument could serve as a complement to a claims-based approach for procedures or groups of procedures for which valuation is thought to be particularly problematic.

Key Findings

  • The overall response rate was 15.5 percent (12.1 percent for cataract surgery, 16.0 percent for hip arthroplasty, and 18.5 percent for complex wound repair).
  • The majority of cataract surgeries occurred in ambulatory surgical centers. Most hip arthroplasties took place in the inpatient hospital setting. Most complex wound repair procedures took place in physician offices.
  • Across all three procedures, most were paid for by Medicare. Commercial coverage was more common for hip arthroplasties and complex wound repair than for cataract surgery.
  • The majority of reported post-operative visits occurred in physician offices.
  • The median time in days from the procedure to the reported visit for cataract surgery was one day; for hip arthroplasty, 22 days; and for complex wound repair, seven days.
  • More visits were expected rather than unexpected.
  • Staff involved in the post-operative visit varied by procedure.
  • Respondents reported that they performed routine, post-operative activities almost all (> 90 percent) of the time, except for care coordination, which occurred about two-thirds of the time for hip arthroplasty and about one-third of the time for cataract surgery and complex wound repair.
  • Reported physician time and work were generally similar — but slightly less — than would be expected from Physician Time File levels for cataract surgery and hip replacement. For complex wound repair, reported physician time and work were higher than would be expected.

Recommendations

  • In selecting procedures, group procedures by body part/system, and survey post-operative visits across the grouping to ensure an adequate number of post-operative visits within the reporting period.
  • The authors focused on an electronic approach to fielding this survey and encountered numerous issues, so future efforts should consider a mailed survey.
  • Medical staff were strongly encouraged to help complete the survey, so framing data collection as a practice-based effort may lead to higher response rates and more accurate information.
  • For future efforts, consider a dedicated support line for the survey with significant investment in personnel to staff the line. Education sessions and material to help respondents prepare for reporting are also recommended.
  • Wherever possible, the survey should be short and simple, though this must be balanced against the need for granular information.
  • Given the strengths and weaknesses of different approaches to collect information on the level of visits, consider a claims-based approach coupled with information about the level of service or the use of G-codes. A survey instrument could serve as a complement to a claims-based approach for procedures or groups of procedures for which valuation is thought to be particularly problematic.

Table of Contents

  • Chapter One

    Background

  • Chapter Two

    Overview of the Current Valuation Approach for Post-Operative Services in the Global Period

  • Chapter Three

    Survey Development and Methods

  • Chapter Four

    Estimating the Level of Post-Operative Visits Through Survey Data

  • Chapter Five

    Lessons Learned and Limitations from Survey Development and Fielding

  • Chapter Six

    Conclusions

  • Appendix A

    Summary of Direct Observation Task

  • Appendix B

    Answers to Frequently Asked Questions (FAQ) About the Survey

  • Appendix C

    Survey Log-In and Informed Consent Text

  • Appendix D

    Survey Screening Questions

  • Appendix E

    Sample Office-Based Visit Module

  • Appendix F

    Sample Practice Characteristics Module

  • Appendix G

    Email Invitation from CMS

  • Appendix H

    Letter from CMS Leadership Accompanying Email

  • Appendix I

    Additional Analyses of Survey Data

  • Appendix J

    ACO-Specific Analyses

Research conducted by

The research described in this report was funded by the Centers for Medicare & Medicaid Services (CMS) and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

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