Expanding the discussion further, one can assess the “ultimate” warranty cost for their own institution (or the amount of money ideally collected on each patient that would allow the institution to cover expenses of the few who develop a complication). In this case (Table 40.2), the total warranty cost ranges from $111 to $2,172 for the elective and open procedures based upon technique. This cost is determined by applying the cost impact of managing the various complications across the entire population managed. Therefore, if a team could further reduce the frequency or cost of managing an issue, the warranty cost could be further reduced. This might include a broader use of laparoscopic procedures with appropriate training or alternatively defining cases better managed in an open fashion to avoid long case time or cost of conversion. This hypothetical analysis demonstrates that for this institution’s colectomy population, elderly patients and urgent or emergent colectomy were all associated with significant increases in warranty cost primarily due to the increased number of complications occurring per patient. Elderly patients typically have a greater preponderance of present on admission conditions that adversely impact the physiologic response to acute illness and surgical intervention and may be only minimally modifiable prior to surgery. The incidence of colonic pathology requiring urgent or emergent surgical intervention is also higher in this population, further augmenting the risk exposure to the provider. Interestingly, the analysis also confirmed that the most costly outcomes are usually multifactorial and unlikely to be mitigated by a globally implemented set of process measures. Instead, it would be more profitable to assess specific components of resource consumption by treatments implemented on a case-by-case basis. Although none of these factors can be directly mitigated, it would be relatively easy to model these risk factors for any potential payer-based population. Recognition of the impact of unavoidable patient characteristics (i.e., severe aortic stenosis in a patient with an obstructing rectal cancer) within a surgical procedure population could avoid forcing providers to accept significant risk without fair compensation or alternatively to “cherry-pick” the population to treat. It is unreasonable to expect the provider to accept the entire risk of managing complicated patients with acute surgical pathology, or worse yet, be the recipient of only the highest risk patients from a given payer without expecting a premium in return. Alternatively, if the payer/provider relationship allowed for nonselective referral, the ECR payment rate could be negotiated based upon the specific demographics and history of the beneficiary pool. Clearly, this would result in an advantageous position versus the current, and often adversarial, fee negotiations that are focused only on lower price—or worse yet, the assumption of poor care. One final concept was that both postoperative ileus and perioperative anemia were important cost drivers, while surgical site infection had no impact on cost structure. This is similar to the work from Wick et al., who demonstrated that consistent improvement in process measure implementation and reporting did not alter the infection rate [22]. Deep organ space infection did complicate the cost of care model; however, the true impact was always related to urgent operations, indicating that acute physiology played a greater role than any current process measure. Importantly, anastomotic leak and the associated downstream complications were considered separately from isolated SSI in this model. This is an important distinction, because any alleged measures for reducing SSI will not likely decrease the anastomotic leak rate. Yet, SSI routinely follows leak development. In addition, attributing outrageously high costs to SSI rather than the complex septic physiology related to anastomotic leaks blurs any rational discussion of cost-effective implementation of SSI reduction strategies [24–26]. The analysis further supports the ECR premise that the average cost per complication had an even stronger negative correlation on cost and margin—the greater the “defect,” the greater the cost of that defect and the providers’ financial risk [29]. Implementation of specific understanding of outcome and cost metrics may be the optimal way to truly “bend the cost curve” for surgical care in the United States. This approach is more precise compared to a concept that all complications can be avoided, or the imprecise application of strategies either unproven or unhelpful in reducing these complications. Providers who can demonstrate superior care and lower cost, documented by a more balanced scorecard approach, would arm consumers with a better framework for decision-making regarding their surgical care.