Disproportionate Share Hospital Research Articles

Comparison of nursing staffing ratio in selected safety net and non-safety net hospitals in the United States

Comparison of nursing staffing ratio in selected safety net and non-safety net hospitals in the United States

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

Considerable racial segregation exists in US hospitals that cannot be explained by where patients live. Approaches to measuring such segregation are limited. To measure how and where sorting of older Black patients to different hospitals occurs within the same health care market. This retrospective cross-sectional study used 2019 Medicare claims data linked to geographic data. Hospital zip code markets were based on driving time. The local hospital segregation (LHS) index was defined as the difference between the racial composition of a hospital's admissions and the racial composition of the hospital's market. Assessed admissions were among US Medicare fee-for-service enrollees aged 65 or older living in the 48 contiguous states with at least 1 hospitalization in 2019 at a hospital with at least 200 hospitalizations. Data were analyzed from November 2022 to January 2024. Degree of residential segregation, ownership status, region, teaching hospital designation, and disproportionate share hospital status. The LHS index by hospital and a regional LHS index by hospital referral region. In the sample of 1991 acute care hospitals, 4 870 252 patients (mean [SD] age, 77.7 [8.3] years; 2 822 006 [56.0%] female) were treated, including 11 435 American Indian or Alaska Native patients (0.2%), 129 376 Asian patients (2.6%), 597 564 Black patients (11.9%), 395 397 Hispanic patients (7.8), and 3 818 371 White patients (75.8%). In the sample, half of hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) exhibited a negative LHS score (ie, admitted fewer Black patients relative to their market area) while 1113 hospitals (45.0%) exhibited a positive LHS (ie, admitted more Black patients relative to their market area); of all hospitals, 79.4% exhibited racial admission patterns significantly different from their market. Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% CI, 0.10 to 0.38), while New York, New York; Chicago, Illinois; and Detroit, Michigan, hospital referral regions exhibited the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21, respectively. In this cross-sectional study, a novel measure of LHS was developed to quantify the extent to which hospitals were admitting a representative proportion of Black patients relative to their market areas. A better understanding of hospital choice within neighborhoods would help to reduce racial inequities in health outcomes.

A safety net for safety net hospitals: Affiliation with cancer centers and survival outcomes in patients with metastatic genitourinary cancers.

543 Background: Safety net hospitals (SNH) care for a substantial proportion of medically vulnerable populations (MVP). Addressing health disparities at a hospital level through partnerships with cancer centers is a potential strategy to improve outcomes of MVPs. We thus compared outcomes for metastatic prostate (mPCa), kidney (mKCa), and urothelial cancer (mUCC) among National Cancer Institute centers (NCI), NCI affiliated SNH (NCI-SNH), and non-affiliated SNH using the Texas Cancer Registry (TCR). Methods: The TCR has 98% case ascertainment of all cancers diagnosed in Texas. The TCR can identify each facility where a patient was diagnosed and treated, allowing detailed hospital level comparisons of outcomes. The TCR was queried from 2004-2017 for mPCa, mKCa, and mUCC. Publicly available data identified Texas NCIs. The top quartile of Disproportionate Share Hospital Index values identified SNH. SNH with established relationships to NCI were designated NCI-SNH and remainder were SNH. Non-SNH were hospitals not affiliated with NCI nor SNH. MVPs were defined as age > 75, non-US natives, non-whites, and uninsured or Medicaid patients. Cox multivariable regression was used to assess overall mortality (OM). Results: Of the 1,048,464 patients in TCR, MVPs accounted for 44.7% of cases. The SNHs and NCI-SNHs accounted for 53.1% of all MVP cancer care statewide. MVPs were the majority of cases within NCI-SNH compared to other SNH or NCI (80% vs 45% vs 37.1%, p<0.01). TCR identified 20,503 metastatic genitourinary (GU) cancers. For mPCa, rates of hormone therapy were similar between NCI-SNH (76.7%) and NCI (76.2%), but greater than SNH (51.5%) or non-SNH (49.7%) ( p<0.01). Receipt of chemotherapy or immunotherapy was greater at NCI-SNH compared to other SNH or non-SNH for both mKCa (36.1% vs 31.1% vs 27.1%, p<0.01) and mUCC (44.0% vs 36.7% vs 33.2%, p<0.01). On multivariable cox analysis, equivalent OM between NCI and NCI-SNH for any metastatic GU cancer (Table). OM was worse at other SNH and non-SNH compared to NCI (Table). Conclusions: Medically vulnerable patients made up almost half of cancer care in Texas and majority were cared for at SNH. NCI-SNHs had equivalent OM to NCI and superior OM compared to other SNH. Future initiatives to improve cancer care should focus on strengthening existing relationships between NCI and SNH, and examine mechanisms to centralize care of MVPs to these facilities.[Table: see text]

Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature.

Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers. We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category. The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission. In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.

Impact of Repeated Reimbursement Penalties on Hospital Total Quality Scores.

The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores. A quantitative comparative analysis of U.S. health care data was conducted. Data on quality outcomes and hospital characteristics were sourced from the Hospital-Acquired Condition Reduction Program from fiscal years 2018 and 2019 and the Centers for Medicare & Medicaid Services Inpatient Prospective Payment System impact files, respectively. In total, 3123 U.S. hospitals were analyzed to compare differences between total HAC scores of hospitals with and without penalties in consecutive years. Hospitals with repeated penalties had significantly greater improvement in scores ( t497.262 = -13.00, P < 0.001), and the impact was greatest in small hospitals (<100 beds). Repeated penalties had a smaller impact on disproportionate share hospitals (Cohen d = 0.73). Among all hospitals, the effect of repeated penalties was large (Cohen d = 0.75). This study suggests that repeated penalties can improve quality scores in U.S. hospitals. However, the effect may be exaggerated for smaller hospitals and those that serve patient populations with a relatively higher socioeconomic status. The reason disproportionate share hospitals did not show as much improvement as nondisproportionate hospitals may be because hospitals serving vulnerable populations often have fewer resources.

Expansion of the 340B Program’s Child Sites and Health Disparities Among Medicare Beneficiaries with Asthma

Background: Under the 340B Drug Pricing Program, drug manufacturers are required to provide discounts to participating safety-net providers including hospitals serving a disproportionate share (DSH) of low-income patients. The program has experienced substantial growth in participating DSH providers due in part to growth in 340B DSH child sites, which are outpatient sites included on the DSH hospitals’ cost report. However, child sites are not required to be easily accessible to vulnerable patients. Objectives: The objective of this study was to determine whether the 340B program’s expansion of child sites was associated with fewer health disparities for asthma-related care. Research Design: We conducted a retrospective analysis of Medicare beneficiaries treated for moderate to severe asthma at 340B DSH hospitals with and without child sites. Measures: We evaluated five drug treatment measures and five adverse outcome measures related to asthma occurring within the first 12 months of the diagnosis date. Results: For Medicare beneficiaries treated for asthma at 340B hospitals with and without child sites, we identified risk-adjusted disparities in drug treatments and adverse health outcomes based on race/ethnicity, dual eligibility status, and socioeconomic status. Statistically significant disparities across the ten outcomes were more likely to occur within 340B hospitals with child sites than 340Bhospitals without child sites. Differences in the magnitudes of the disparities varied by vulnerable subgroup. Conclusions: Our findings suggest that the growth in 340B child sites have not universally expanded access to higher quality care for vulnerable patients, and as such policy changes may be needed.

An assessment of completeness and medical coding of Medicare Advantage hospitalizations in two national data sets.

To compare the Encounter Data System (EDS) and Medicare Provider Analysis and Review (MedPAR) completeness and medical coding of Medicare Advantage hospitalizations. FY 2016-FY 2019 data limited to hospitals paid under Medicare's Inpatient Prospective Payment System. Secondary data analysis. Completeness of EDS and MedPAR data was estimated using the total number of unique hospitalizations in both data sources as denominator. Deriving this denominator involved matching cases in the EDS and MedPAR by MA enrollee, discharge date, and hospital. The higher the match rate, the more informative the comparison of EDS and MedPAR medical coding of the same hospitalization. EDS and MedPAR codes were assessed for similarity on six measures of Medicare Severity Diagnosis-Related Group (MS-DRG) assignment and identical diagnosis and procedure codes. EDS hospitalizations' completeness increased steadily each year from 90% to 93%, driven by the 23 largest Medicare Advantage Organizations, which account for 83% of total cases. MedPAR completeness was relatively stable (89%) and benefited from 91% completeness among the largest hospitals, which are often teaching hospitals and account for 63% of MedPAR cases. By 2019, 97% of medical cases were assigned the same MS-DRG, indicating the high consistency of the severity level coding, since 98% were assigned the same base MS-DRGs, which include all severity levels for the same condition. Without chart reviews, medical cases with identical diagnosis codes increased from 87% to 92%. The EDS has a completeness advantage over MedPAR for studies of non-teaching disproportionate share (DSH) hospitals and individual hospitals generally. MedPAR is only slightly less complete for hospitalizations of teaching DSH hospitals and large hospitals in general. A highly consistent EDS and MedPAR medical coding of matched cases is an important finding since the matched cases are 88% of EDS and 90% of MedPAR cases.

Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries.

This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality. This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included. For the market-level analysis, we assessed the association of social vulnerability with the presence of a high-quality hip and knee replacement center. For the hospital-level analysis, we assessed the association of disproportionate share hospital (DSH) percentage with each high-quality designation. Healthcare markets were approximated by hospital referral regions. All associations were assessed with fractional regressions using generalized linear models with binomial family and logit links. We found that healthcare markets in the most vulnerable quartile were less likely to have a hip and knee replacement hospital that did better than the national average (odds ratio [OR] 0.22, P = 0.02) but not more or less likely to have a hospital certified as advanced by JC (OR 0.41, P = 0.16). We found that hip and knee replacement hospitals in the highest DSH quartile were less likely to be designated by the Centers for Medicare and Medicaid Services as better than the national average (OR 0.18, P = 0.001) but not more or less likely to be certified as advanced by JC (OR 1.40, P = 0.28). Geographic distribution of high-quality hospitals may contribute to socioeconomic disparities in patients' access to and utilization of high-quality hip and knee replacement. Equal access to and utilization of hospitals with high-quality surgical processes does not necessarily indicate equitable access to and utilization of hospitals with high-quality outcomes. Level III.

Association of Total Knee Replacement Removal From the Inpatient-Only List With Outpatient Surgery Utilization and Outcomes in Medicare Patients

Little is known about the association of total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 with outcomes in Medicare patients. To evaluate (1) patient factors associated with outpatient TKR use and (2) whether the IPO policy was associated with changes in postoperative outcomes for patients undergoing TKR. This cohort study included data from administrative claims from the New York Statewide Planning and Research Cooperative System. Included patients were Medicare fee-for-service beneficiaries undergoing TKRs or total hip replacements (THRs) in New York State from 2016 to 2019. Multivariable generalized linear mixed models were used to identify patient factors associated with outpatient TKR use, and with a difference-in-differences strategy to examine association of the IPO policy with post-TKR outcomes relative to post-THR outcomes in Medicare patients. Data analysis was performed from 2021 to 2022. IPO policy implementation in 2018. Use of outpatient or inpatient TKR; secondary outcomes included 30-day and 90-day readmissions, 30-day and 90-day postoperative emergency department visits, non-home discharge, and total cost of the surgical encounter. A total of 37 588 TKR procedures were performed on 18 819 patients from 2016 to 2019, with 1684 outpatient TKR procedures from 2018 to 2019 (mean [SD] age, 73.8 [5.9] years; 12 240 female [65.0%]; 823 Hispanic [4.4%], 982 non-Hispanic Black [5.2%], 15 714 non-Hispanic White [83.5%]). Older (eg, age 75 years vs 65 years: adjusted difference, -1.65%; 95% CI, -2.31% to -0.99%), Black (-1.44%; 95% CI, -2.81% to -0.07%), and female patients (-0.91%; 95% CI, -1.52% to -0.29%), as well as patients treated in safety-net hospitals (disproportionate share hospital payments quartile 4: -18.09%; 95% CI, -31.81% to -4.36%), were less likely to undergo outpatient TKR. After IPO policy implementation in the TKR cohort, there were lower adjusted 30-day readmissions (adjusted difference [AD], -2.11%; 95% CI, -2.73% to -1.48%; P < .001), 90-day readmissions ( -3.23%; 95% CI, -4.04% to -2.42%; P < .001), 30-day ED visits ( -2.45%; 95% CI, -3.17% to -1.72%; P < .001), 90-day ED visits (-4.01%; 95% CI, -4.91% to -3.11%; P < .001) and higher cost per encounter ($2988; 95% CI, $415 to $5561; P = .03). However, these changes did not differ from changes in the THR cohort except for increased TKR cost of $770 per encounter ($770; 95% CI, $83 to $1457; P = .03) relative to THR. In this cohort study of patients undergoing TKR and THR, we found that older, Black, and female patients and patients treated in safety-net hospitals may have had lesser access to outpatient TKRs highlighting concerns of disparities. IPO policy was not associated with changes in overall health care use or outcomes after TKR, except for an increase of $770 per TKR encounter.

Interoperability among hospitals treating populations that have been marginalized.

To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized. Data on 2393 non-federal acute care hospitals in the United States from the American Hospital Association Information Technology Supplement fielded in 2021, the 2019 Medicare Cost Report, and the 2019 Social Deprivation Index. Cross-sectional analysis. We identified five proxy measures related to marginalization and assessed the relationship between those measures and the likelihood that hospitals engaged in all four domains of interoperable information exchange and participated in national interoperability networks in cross-sectional analysis. In unadjusted analysis, hospitals that treated patients from zip codes with high social deprivation were 33% less likely to engage in interoperable exchange (Relative Risk = 0.67, 95% CI: 0.58-0.76) and 24% less likely to participate in a national network than all other hospitals (RR = 0.76; 95% CI: 0.66-0.87). Critical Access Hospitals (CAH) were 24 percent less likely to engage in interoperable exchange (RR = 0.76; 95% CI: 0.69-0.83) but not less likely to participate in a national network (RR = 0.97; 95% CI: 0.88-1.06). No difference was detected for 2 measures (high Disproportionate Share Hospital percentage and Medicaid case mix) while 1 was associated with a greater likelihood to engage (high uncompensated care burden). The association between social deprivation and interoperable exchange persisted in an analysis examining metropolitan and rural areas separately and in adjusted analyses accounting for hospital characteristics. Hospitals that treat patients from areas with high social deprivation were less likely to engage in interoperable exchange than other hospitals, but other measures were not associated with lower interoperability. The use of area deprivation data may be important to monitor and address hospital clinical data interoperability disparities to avoid related health care disparities.

PO-03-182 ASSESSMENT OF PRICE VARIATION IN CARDIOVASCULAR CATHETER ABLATIONS AT US HOSPITALS

Ablation of atrial fibrillation (AF) and ventricular tachycardia (VT) comprise a significant proportion of catheter ablation procedures. However, few studies have explored the commercial cost footprint of these procedures, despite the 2021 Hospital Price Transparency Final Rule mandating US hospitals publish their insurer-negotiated prices. This study sought to characterize and identify factors contributing to variation in AF and VT ablation prices across the US. We queried a commercial database containing hospital-disclosed prices to characterize variation in ablation procedure prices within and across US hospitals. This price data was linked to hospital characteristics using Medicare Facility IDs. Univariate analysis was conducted to compare median prices across multiple factors. In total, 1,030 hospitals reported commercial prices for AF ablation, while 1,006 reported prices for VT ablation. For AF ablation, median prices were higher at major investor-owned facilities (p<0.01), while for VT ablation, investor-owned facilities had lower prices (p<0.01). For both AF and VT ablation, the New England region exhibited the highest median price ($28,141 and $28,145, respectively), while the Middle Atlantic exhibited the lowest median price ($16,829 and $15,666, respectively). Higher prices were associated with better than average all-cause readmission rates (p<0.01 for AF and VT ablation) and higher patient hospital ratings (p<0.01 for both). However, CMS hospital ratings (AF: p=0.42; VT: p=0.08) and hospital-wide mortality were not associated with price (AF: p=0.36; VT: p=0.56). For both AF and VT ablation, commercial rates did not differ widely from the Medicare price. Within hospitals, the 90th percentile payer-negotiated rate was 2.42 (IQR 1.34-4.61) times the 10th percentile rate (within-center ratio) for AF ablation and 2.40 (IQR 1.41-5.16) for VT ablation. Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 1.54 (IQR 1.00-2.63) times that at the 10th percentile hospital (between-center ratio) for AF ablation and 1.47 (IQR 1.00-2.61) for VT ablation. Prices for ablation procedures varied widely within and between hospitals. Commercial markup from the Medicare price was limited. Several factors correlated closely with reimbursement, including hospital-wide readmissions and patient ratings. However, there was no association between price and hospital-wide mortality or CMS rating.Tabled 1Univariate Analysis of Factors Associated with Cardiovascular Catheter Ablations Commercial Price (PO-03-182)Atrial Fibrillation AblationVentricular Tachycardia AblationCategorical Values(% Reporting)# ofHospitals(%)MedianPrice($)IQR($)P-Value †# ofHospitals(%)MedianPrice($)IQR($)P-Value †Region (92.1, 92.4)<0.01<0.01 New England (CT, MA, ME, NH, RI, VT)Middle Atlantic (NJ, NY, PA)South Atlantic (DC, DE, MD, VA, WV, C, SC, GA, FL)East North Central (OH, IN, IL, MI, WI)East South Central (KY, TN, AL, MS)West North Central (MN, IA, MO, ND, SD, NE, KS)West South Central (AR, LA, OK, TX)Mountain (MT, ID, WY, CO, NM, AZ, UT, NV)Pacific (WA, OR, CA, AK, HI)37 (3.9)112 (11.8)226 (23.8)188 (19.8)79 (8.3)97 (10.2)140 (14.8)42 (4.4)28 (3.0)28141168291808220065215512439926517258912460626243-305588362-2330411750-2588211817-2913316087-2799216203-2839416641-3176322631-3315017616-3916037 (4.0)108 (11.6)226 (24.3)176 (18.9)81 (8.7)91 (9.8)142 (15.3)40 (4.3)29 (3.1)28145156661808217831211982081224674258892727725174-309468071-2164711019-2589111817-2823914531-2789011792-2672412432-3169522516-3274423006-42535Hospital Type (88.7, 89.2)0.06<0.01 For-ProfitNot-For-ProfitGovernment194 (21.2)651 (71.2)69 (7.5)21798216562256111338-2817712739-3033818147-31958190 (21.2)640 (71.3)67 (7.5)1734020544233759273-2646612003-3020416843-36485Major Investor Owned (96.6, 96.7)<0.01<0.01 Major Investor OwnedNot Major Investor Owned222 (22.3)773 (77.7)221512002711751-2798113330-30470215 (22.1)758 (77.9)16841211819273-2588912720-30719Teaching Status (92.1, 92.4)0.830.59 Major TeachingMinor TeachingNon-Teaching132 (13.9)624 (65.8)193 (20.3)21940216132165611551-3022112443-2962315899-30347129 (13.9)492 (52.9)309 (33.2)20856198602085510934-3090211763-2852812365-28998Urban/Rural (99.9, 100.0)0.760.35 UrbanRural937 (91.1)92 (8.9)217882167712584-2960114804-30488917 (91.2)89 (8.8)201252161911823-2895314803-29936Disproportionate Share Hospital (82.4, 83.0)0.02<0.01 Disproportionate Share Hospital (DSH)Sole Community Hospital (not DSH-eligible)Not DSH692 (81.5)38 (4.5)119 (14.0)21583264502113412124-2958119779-3331412829-30029684 (81.9)35 (4.2)116 (13.9)19706263661900511782-2885921826-3236511935-28034CMS Hospital-Wide Mortality (80.4, 80.7)0.360.56 Above National AverageSame as National AverageBelow National Average159 (19.2)553 (66.8)116 (14.0)21470216212383713394-30164127226-2968912021-32762158 (19.5)537 (66.1)117 (14.4)19465203562162111985-2811311854-2927311834-33024CMS Hospital-Wide Readmission Rate (82.2, 82.7)<0.01<0.01 Above National AverageSame as National AverageBelow National Average346 (40.9)123 (14.5)378 (44.6)23431237131916215948-3173916936-2945211091-28180340 (40.9)121 (14.5)371 (44.6)22515221981855914028-3145011730-3021710846-27912HCAHPS Patient Overall Hospital Rating (80.8, 81.2)<0.01<0.01 1234540 (4.8)149 (17.9)303 (36.4)311 (37.4)29 (3.5)156711863621198243192950211775-2284713066-2704511718-2878915103-3175120076-3437136 (4.4)142 (17.4)298 (36.5)312 (38.2)29 (3.5)168121684519526239822823610945-2206610870-2393610687-2799114446-3180418905-34272CMS Overall Hospital Rating (82.0, 83.2)0.420.08 1234543 (5.1)160 (18.9)246 (29.1)264 (31.2)132 (15.6)184712122321716223762208312445-2486412816-2831411471-2992111841-3046515648-3180541 (4.9)154 (18.6)244 (29.4)260 (31.3)131 (15.8)154061861620466203732252710378-2254411751-2589311228-2914511782-3060212829-31296† Comparisons were done via the Kruskal-Wallis test. 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PO-03-184 ASSESSMENT OF PRICE VARIATION IN PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE DEVICE PROCEDURES AT US HOSPITALS

Since their approval in the US in 2015, left atrial appendage closure (LAAC) devices have served as an alternative to oral anticoagulation in atrial fibrillation (AF) patients at increased risk of bleeding. However, few studies have explored the commercial cost footprint of LAAC procedures, despite the 2021 Hospital Price Transparency Final Rule mandating US hospitals publish their insurer-negotiated prices. This study sought to characterize and identify factors contributing to variation in LAAC procedure prices across the US. We queried a commercial database containing hospital-disclosed prices to characterize variation in LAAC procedure prices within and across US hospitals. We then linked this price data to hospital characteristics using Medicare Facility IDs. Univariate analysis was conducted to compare commercial prices across multiple factors. In total, 683 hospitals reported commercial prices for LAAC procedures. Among reporting hospitals, median prices were greater at major investor-owned vs. non-major investor-owned facilities ($10,991 vs. $7,227, p<0.01) and for-profit centers vs. not-for-profit and government centers ($10,991 vs. $7,417 vs. $5,051, p<0.01). Prices were also greater at non-teaching hospitals compared to minor and major teaching hospitals (p<0.01). The Pacific region exhibited the highest median price ($18,652), while the Middle Atlantic exhibited the lowest median price ($5191). There was no association between price and CMS hospital-wide mortality (p=0.21) or all-cause readmissions (p=0.29). Patient hospital ratings were correlated with price (p<0.01) but not CMS overall hospital ratings (p=0.62). Commercial and self-pay prices were 2.30- and 2.61-times higher than the Medicare price. Within hospitals, the 90th percentile payer-negotiated rate was 2.0 (IQR 1.00-4.06) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 1.54 (IQR 1.00-2.63) times that at the 10th percentile hospital (between-center ratio). Prices for LAAC procedures varied widely, with commercial and self-pay rates over double the Medicare price. Within-center variation in price was higher than between-center variation. Non-teaching, investor-owned, and for-profit hospitals had higher prices; however, there was no association between prices and hospital-wide mortality or readmission rates.Tabled 1Univariate Analysis of Factors Associated with Left Atrial Appendage Closure Device Procedures Commercial PriceCategorical Values (% Reporting)# ofHospitals (%)Median Price ($)Interquartile Range ($)P-ValueRegion (93.6)<0.01 New England (CT, MA, ME, NH, RI, VT)Middle Atlantic (NJ, NY, PA)South Atlantic (DC, DE, MD, VA, WV, C, SC, GA, FL))East North Central (OH, IN, IL, MI, WI)East South Central (KY, TN, AL, MS)West North Central (MN, IA, MO, ND, SD, NE, KS)West South Central (AR, LA, OK, TX)Mountain (MT, ID, WY, CO, NM, AZ, UT, NV)Pacific (WA, OR, CA, AK, HI)26 (4.1)59 (9.2)157 (24.6)119 (18.6)57 (8.9)78 (12.2)107 (16.7)26 (4.1)10 (1.6)90915191104657682113425900719911150186524865-125783839-94483652-145313562-113323005-152592780-124784030-114763094-122562891-26874Hospital Type (87.8)<0.01 For-ProfitNot-For-ProfitGovernment154 (25.7)407 (67.8)39 (6.5)10991741750516853-152603077-124772731-14581Major Investor Owned (96.8)<0.01 Major Investor OwnedNot Major Investor Owned173 (26.2)488 (73.8)1099172276997-152603050-12344Teaching Status (93.6)<0.01 Major TeachingMinor TeachingNon-Teaching84 (13.1)332 (52.0)223 (34.9)56488012106162475-91313340-123443840-15260Urban/Rural (100)0.06 UrbanRural620 (90.8)63 (9.2)823488373428-129183634-13784Disproportionate Share Hospital (82.3)0.63 Disproportionate Share Hospital (DSH)Sole Community Hospital (not DSH-eligible)Not DSH474 (84.3)14 (2.5)74 (13.2)81681073987693510-129885052-128633241-14189CMS Hospital-Wide Readmission Rate (82.6)0.26 Above National AverageSame as National AverageBelow National Average227 (40.2)80 (14.2)257 (45.6)8633863286493340-133264079-142673840-12579CMS Hospital-Wide Mortality (80.7)0.25 Above National AverageSame as National AverageBelow National Average99 (18.0)375 (68.1)77 (14.0)8819823789043486-119703544-132163473-15159HCAHPS Patient Overall Hospital Rating (81.1)<0.01 1234517 (3.1)96 (17.3)211 (38.1)209 (37.7)21 (3.8)10991875869649044136316295-205573635-128202856-112883844-146829078-18372CMS Overall Hospital Rating (83.1)0.62 1234526 (4.6)92 (16.2)160 (28.2)186 (32.7)104 (18.3)922490048620761886934492-120864918-126313632-130232864-132513803-13693Comparisons were done via the Kruskal-Wallis test. Open table in a new tab

Analysis of Hospital Operating Margins and Provision of Safety Net Services

Safety net hospitals (SNH) provide many community services. The cost of providing these services is unknown. To determine what safety net criteria are associated with differences in hospital operating margin. This cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports. Five domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index. Operating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates. A total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin. In this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.

Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program.

Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program.

Variation in Cost of Echocardiography Within and Across United States Hospitals

While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated that U.S. hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices. We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked these price data to hospital and regional characteristics using Medicare Facility IDs. A total of 1,949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93 and 3.06 times greater than the median Medicare price ($1,313 and $1,422, respectively, vs $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (interquartile range, 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region, the median price at the 90th percentile hospital was 2.47 (interquartile range, 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (P=.04), teaching (P<.01), investor-owned (P<.01), and higher-rated hospitals (P<.01) charged higher prices, whereas rural referral centers (P=.01) and disproportionate share hospitals (P<.01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except for investor ownership and rural referral centers. Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. A better understanding of the relationship between this cost variation and quality of care is critical given the impact of cost on health care access and affordability.

The Early Impact of the COVID-19 Pandemic on Hospital Finances.

The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.

The 340B Program and Health Disparities Among Medicare Beneficiaries With Chronic Asthma.

The study objective was to determine whether the discounts provided under the 340B program help address disparities in drug treatment and adverse outcomes among Medicare Fee-For-Service (FFS) beneficiaries initially Medicare-diagnosed with moderate to severe chronic asthma. Using Medicare FFS claims data from 2017 to 2019, we conducted a cross-sectional study that compared risk-adjusted differences in 5 treatment measures and 5 adverse outcomes among beneficiaries treated within 340B and non-340B hospital systems that met the disproportionate share (DSH) criteria and the ownership classification requirement to qualify as a 340B DSH hospital. Our analysis focused on potential disparities that are historically associated with challenges to accessing quality health care. We did not observe fewer disparities in drug treatments or adverse outcomes for beneficiaries with moderate to severe asthma treated at 340B hospital systems compared to non-340B hospital systems. These results raise questions as to whether 340B hospital systems are effectively using discounts to focus on improved access and outcomes for vulnerable beneficiaries.

Variation And Changes In The Targeting Of Medicaid Disproportionate Share Hospital Payments.

Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have changed over time. We employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1percent), hospitals with uncompensated care shares above the state-specific median (60.6percent), or hospitals deemed as disproportionate share per statutory definitions (64.6percent). However, among all hospitals receiving these payments, up to 31.6percent of payments were allocated to hospitals that did not meet a given definition, and 3.2percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.

Structural Racial Disparities in the Allocation of Disproportionate Share Hospital Payments

This cross-sectional study examines the allocation of Medicare and Medicaid Disproportionate Share Hospital payments by race.

Association Between Cancer Center Accreditation and Compliance With Price Disclosure of Common Oncologic Surgical Procedures.

Cancer center accreditation status is predicated on several factors that measure high-value healthcare. However, price transparency, which is critical in healthcare decisions, is not a quality measure included for accreditation. We reported the rates of price disclosure of surgical procedures for 5 cancers (breast, lung, cutaneous melanoma, colon, and prostate) among hospitals ranked by the American College of Surgeon's Commission on Cancer (ACS-CoC). We identified nonfederal, adult, and noncritical access ACS-CoC accredited hospitals and used the commercial Turquoise Health database to perform a cross-sectional analysis of hospital price disclosures for 5 common oncologic procedures (mastectomy, lobectomy, wide local excision for cutaneous melanoma, partial colectomy, prostatectomy). Publicly available financial reporting data were used to compile facility-specific features, including bed size, teaching status, Centers for Medicare & Medicaid wage index, and patient revenues. Modified Poisson regression evaluated the association between price disclosure and ACS-CoC accreditation after adjusting for hospital financial performance. Of 1,075 total ACS-CoC accredited hospitals, 544 (50.6%) did not disclose prices for any of the surgical procedures and only 313 (29.1%) hospitals reported prices for all 5 procedures. Of the 5 oncologic procedures, prostatectomy and lobectomy had the lowest price disclosure rates. Disclosing and nondisclosing hospitals significantly differed in ACS-CoC accreditation, ownership type, and teaching status. Hospitals that disclosed prices were more likely to receive Medicaid disproportionate share hospital payments, have lower average charge to cost ratios (4.53 vs 5.15; P<.001), and have lower net hospital margins (-2.03 vs 0.44; P=.005). After adjustment, a 1-point increase in markup was associated with a 4.8% (95% CI, 2.2%-7.4%; P<.001) higher likelihood of nondisclosure. More than half of the hospitals did not disclose prices for any of the 5 most common oncologic procedures despite ACS-CoC accreditation. It remains difficult to obtain price transparency for common oncologic procedures even at centers of excellence, signaling a discordance between quality measures visible to patients.