Healthcare Cost Report Information System Research Articles

THE IMPACT OF CONTRACT NURSE UTILIZATION ON NURSING HOME QUALITY

Abstract Nurse staffing intensity and skill mix have a significant impact on NH quality of care. For instance, higher staffing levels, particularly for registered nurses (RNs), have been associated with better resident outcomes. NHs have increasingly relied on contract nurse staffing to address pressing and persistent nursing shortages. Research suggests that contract nurses may be unfamiliar with institutional policies and procedures or organizational culture. They may require increased supervision, be less participatory in teamwork, and may increase the workload for the permanent staff. The objective of this study is to examine the association between contract nurse utilization and quality of care at US nursing homes.We used secondary data from PBJ nurse staffing, Nursing Home Compare, Healthcare Cost Report Information System (HCRIS) Dataset, and the American Community Survey (ACS) for the period 2017-2021. The dependent variable was CMS quality star rating, and the independent variables were contract nurse to total nurse proportions for each of RNs, LPNs, and CNAs. We employed multivariate random effects ordered logistic regression to test the hypothesis. We found that across all our three models (RNs, LPNs, CNAs), quality star ratings were negatively associated with contract nurse utilization. A 10% increase in contract nurse proportion was associated with a 10% decrease in the odds of reporting a higher quality star rating (OR=0.99, p<0.001). Our results suggest the increased utilization of contract nurse staffing may have a negative impact on US NH quality---an important issue that has agitated policymakers for nearly three decades.

FROM COMFORT TO PROFITABILITY: RELATIONSHIP BETWEEN CARE QUALITY AND FINANCIAL PERFORMANCE IN US HOSPICES

Abstract Hospice care is a critical aspect of end-of-life care in the United States, providing comfort and support to individuals with life-limiting illnesses. Quality of care is a key concern for hospice facilities, as it can impact both patient outcomes and financial sustainability. Poor quality of care can lead to negative patient experiences, increased hospitalizations, and even legal issues. It can also result in financial penalties or reduced reimbursement from payers. However, there is limited research on the relationship between quality of care and financial performance in hospice facilities. Employing a cross-sectional observational design, we examined the relationship between Hospice and Palliative Care Composite Process Measure (lagged by 1 year) and the total margin of hospice facilities across the United States. We used secondary data from Nursing Home Compare, Healthcare Cost Report Information System Dataset, and the American Community Survey for the period 2017-2021. We found a positive association between quality process measures and financial performance in hospice facilities after controlling for organizational and community factors that may influence financial performance, such as facility size and location. Specifically, a 10-unit increase in quality measure was associated with a 2% increase in total margin. The findings of this study have important implications for the management and financing of hospice facilities. Investments in quality improvement initiatives may lead to improved financial performance. Policymakers should consider these findings when designing payment systems for hospice care, and administrators of hospice facilities should prioritize quality improvement initiatives to ensure both high-quality care and financial viability.

Rates of price disclosure associated with the surgical treatment of early-stage breast cancer oneyear after implementation of federal regulations.

Mastectomy, breast reconstruction (BR) and breast conserving therapy (BCT) are core components of the treatment paradigm for early-stage disease but are differentially associated with significant financial burdens. Given recent price transparency regulations, we sought to characterize rates of disclosure for breast cancer-related surgery, including mastectomy, BCT, and BR (oncoplastic reconstruction, implant, pedicled flap and free flap) and identify associated factors. For this cross-sectional analysis, cost reports were obtained from the Turquoise Health price transparency platform for all U.S. hospitals meeting national accreditation standards for breast cancer care. The Healthcare Cost Report Information System was used to collect facility-specific data. Addresses were geocoded to identify hospital referral and census regions while data from CMS was also used to identify the geographic practice cost index. We leveraged a Poisson regression model and relevant Medicare billing codes to analyze factors associated with price disclosure and the availability of an OOP price estimator. Of 447 identified hospitals, 221 (49.4%) disclosed prices for mastectomy and 188 42.1%) disclosed prices for both mastectomy and some form of reconstruction including oncoplastic reduction (n = 184, 97.9%), implants (n = 187, 99.5%), pedicled flaps (n = 89, 47.3%), and free flaps (n = 81, 43.1%). Non-profit status and increased market competition were associated with price nondisclosure. 121 hospitals (27.1%) had an out-of-pocket price estimator that included at least one breast surgery. Most eligible hospitals did not disclose prices for breast cancer surgery. Distinct hospital characteristics were associated with price disclosure. Breast cancer patients face persistent difficulty in accessing costs.

Non-operating revenue is an important source of funding for rural hospitals, especially those that are government-owned.

Non-operating revenue (NOR), derived from investments, contributions, government appropriations, and medical space rentals, can contribute to financial stability of hospitals by offsetting operating losses and improving profitability. NOR might benefit rural hospitals that often face intense financial pressures. However, little is known about how much rural hospitals rely on NOR and if certain organizational characteristics are associated with differences in NOR. Healthcare Cost Report Information System data from 2011 to 2019 were used to analyze sources of revenue among Critical Access Hospitals (CAHs) and Rural Prospective Payment System (R-PPS) hospitals through descriptive statistics and regression models. Reliance on NOR was measured by the percentage of total revenue from non-operating sources. Results indicate that both CAHs and R-PPS hospitals rely on NOR; however, CAHs have a higher percentage of total revenue derived from non-operating sources (3.2%) as compared to R-PPS hospitals (1.9%) (p < 0.001). Government-owned hospitals have significantly higher reliance on NOR than other ownership types. System affiliation also influences reliance on NOR. Lastly, results suggest that NOR may play a role in improving overall profit margins. As rural hospitals disproportionately face challenges related to declining profitability and the risk for closure, they may rely on NOR to continue to strengthen financial performance and provide health care to their communities. However, NOR is not guaranteed, and reliance on NOR further reiterates the value of stable, adequate reimbursement to guard against fluctuations in NOR.

Characteristics of short-term acute care hospitals that experienced a ransomware attack from 2016 to 2021.

As cybercrime increasingly targets the health care sector, hospitals face the growing threat of ransomware attacks. Ransomware is a type of malicious software that prevents users from accessing their electronic systems-demanding payment to restore access. In response, momentum is gathering to enact policy that will help hospitals strengthen their cybersecurity defenses. However, to design effective policy, it is crucial to understand the characteristics of hospitals associated with the risk of ransomware attack. In this paper, we compare the characteristics of ransomware-attacked and non-attacked short-term acute care hospitals in the United States. Using data from the American Hospital Association's Annual Survey and the Healthcare Cost Report Information System, we found that ransomware-attacked hospitals were larger, had higher net operating revenue, were more likely to be financially profitable, and more likely to provide trauma, emergency, and obstetric care than non-attacked hospitals. Measures of information technology sophistication did not vary between ransomware-attacked and non-attacked hospitals. These results can be used to tailor policy interventions in order to most effectively respond to and prevent cybercrime in health care.

Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes

Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Paycheck Protection Program loan receipt status. Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664 349 (IQR, $407 000-$1 058 300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P < .001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week). In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages.

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 Effects of the Medicaid Expansion on Hospital Utilization, Employment, and Capital.

In recent years, hospitals reacted to changes in demand caused by the Affordable Care Act Medicaid expansions. We conducted a difference-in-differences analysis that compared changes to hospital demand and supply in Medicaid expansion and nonexpansion states. We used 2010-2016 data from the American Hospital Association and the Healthcare Cost Report Information System to quantify changes to hospital utilization and characterize how hospitals adjusted labor and capital inputs. During the period studied, the Medicaid expansion was associated with increases in emergency department visits and other outpatient hospital visits. We find strong evidence that hospitals met increases in demand by hiring nursing staff and weaker evidence that they increased hiring of technicians and investments in equipment. We found no evidence that hospitals adjusted hiring of physicians, support staff, or investments in other capital inputs.

Sunday, June 19, 202211:30 AM - 12:30 PMGSOR13 Presentation Time: 11:30 AM: Factors Associated with Hospital-Negotiated Prices of Tandem & Ovoids in the U.S. in 2021

<h3>Purpose</h3> HDR brachytherapy, such as tandem & ovoids (T&O), is a crucial component of definitive care for locally advanced cervical cancer in the U.S. Its cost and those of other healthcare services are often unknown or unclear at the time of care. Upfront, accessible price transparency may help address patients' financial concern. Effective 1/1/2021, the Hospital Price Transparency Rule (45 CFR Part 180) requires all U.S. hospitals to annually release hospital-related prices. Our project seeks to evaluate the availability, variation, and factors associated with hospital-negotiated prices of T&O in the U.S. <h3>Materials and Methods</h3> We conducted a cross-sectional study of U.S. hospitals in CMS's Care Compare, linking to Turquoise Health (hospital-negotiated prices), Healthcare Cost Report Information System (hospital characteristics), and Social Vulnerability Indices. We identified six T&O-related CPT codes (77280, 77470, 77370, 77318, 77771, and 57155), with their negotiated-prices estimated by payer type. We used regression models to estimate the association of hospital characteristics with commercial prices. <h3>Results</h3> A majority of the hospitals are non-profit (61%), acute care hospitals (69%), and/or non Graduate Medical Education (GME)-participating (72%), with a median operating margin of 0.03 (IQR:-0.03, 0.09), asset-to-liability ratio of 1.79 (1.06, 2.96), and social vulnerability index of 0.53 (0.29, 0.74). 17-28% of hospitals reported T&O-related prices depending on the CPT code. Prices were typically greater for commercial insurance compared to Medicare/Medicaid (+$335-362 simulation, +$550-798 MD plan, +$224-747 physics plan, +$1160-1707 treatment; P<0.001, all tests), except for CPT code 57155 (treatment) where the Medicare price was greater than commercial insurance's price (+403; P<0.001). Table 1 shows the adjusted analysis of commercial prices. <h3>Conclusion</h3> Our analysis shows that negotiated T&O prices in the U.S. is typically higher for commercial insurances, hospitals with higher operating margins, and non GME participating hospitals; it is typically lower for critical access hospitals. Socially vulnerable areas do not consistently enjoy lower prices. Further price transparency research and advocacy could better elucidate this area, thereby promoting economic competition and lower the price for curative cervical cancer treatment.

Factors associated with U.S. hospital payer-specific negotiated mammography charges.

e13633 Background: The Hospital Price Transparency Rule, effective 1/1/2021, requires hospitals to publish payer-specific negotiated charges and cash prices. Given differences in insurance coverage for screening versus diagnostic mammography, we evaluate factors associated with these payer-negotiated charges. Methods: We conducted a cross-sectional study of U.S. acute care and critical access hospitals in CMS’ Care Compare linked to Turquoise Health (payer-negotiated charges), Healthcare Cost Report Information System (hospital characteristics) and Social Vulnerability Indices by county. Negotiated charges for mammography (CPT: screening 77067; diagnostic unilateral 77065, bilateral 77066) were estimated by payer type (self-pay, managed Medicare/Medicaid, or commercial). Adjusted models estimated commercial charges accounting for hospital factors. Results: Most hospitals (N=4212) were non-profits (61%) and acute care hospitals (69%). Median operating margin was .03 (IQR:-.03, .09), asset-to-liability ratio was 1.79 (1.06, 2.96), and social vulnerability index was .53 (.29, .74). 48-50% reported mammography charges. Charges were greater for commercial insurance compared to Medicare/Medicaid (+$55-$82 screening, +$122-$132 bilateral diagnostic; P&lt;.001, all tests). Charges for commercial insurance were similar to self-pay for bilateral screening (p=.41) and diagnostic (p=.08) mammography. See Table for adjusted analysis of commercial charges. Conclusions: Our analysis showed U.S. negotiated mammography charges are similar for self-pay and commercial payers. Commercial charges are higher at private hospitals and those with higher operating margins for diagnostic exams, and lower in socially vulnerable areas. Price transparency may promote competition to lower healthcare prices and highlight any financial toxicity associated with self-pay charges. [Table: see text]

Is Skilled Nursing Facility Financial Status Related to Readmission Rate Improvement?

We examined whether higher skilled nursing facility (SNF) lagged profitability is associated with a lower 30-day all-cause all-payer risk-adjusted hospital readmission rate. Our aim was to provide insight into whether SNFs with limited financial resources are able to respond to incentives to lower their readmission rates to hospitals. We used data from 2012-2016 to estimate a fixed effects (FE) model with a time trend. Our data included financial data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System SNF cost reports, facility characteristics including the all-cause all-payer risk-adjusted unplanned 30-day readmission rate from the LTCFocus (Long-Term Care Focus) project at Brown University, and county-level market variables from the Area Health Resource File. We also examined the relationship for a shorter time frame (2012-2015) after stratifying the sample by system membership or ownership. SNFs with an increase in the lagged operating margin showed a statistically significant, small decrease (<.01 percentage point) in the risk-adjusted readmission rate. The results were robust for different time periods and model specifications. Fixed effects model estimates for SNFs in the highest quartile of percentage of Medicaid patients (≥73.9%) had a lagged operating margin coefficient that is almost four times as large as the coefficient of the FE model with all SNFs. SNFs have an important role in achieving the national priority of reducing hospital readmissions. The study findings suggest that managers of SNFs should not see low profitability as an obstacle to reducing readmission rates, which is good news given the low average profitability of SNFs. Further, reductions in profitability due to penalties incurred from the recently implemented Medicare Skilled Nursing Facility Value-Based Purchasing Program may not limit SNFs' ability to lower hospital readmission rates, at least initially. However, policymakers may need to determine whether additional resources to high Medicaid SNFs can lower readmission rates for these SNFs.

Telehealth Adoption and Discontinuation by US Hospitals: Results From 2 Quasi-Natural Experiments.

BackgroundPrior US hospital telehealth (video visit) studies have focused on describing factors that influence telehealth adoption or performance effects for specific patient segments, hospital systems, or geographic regions. To our knowledge, a larger-scale, national-level (US) study has yet to be conducted on the causal impacts of hospital telehealth adoption as well as discontinuation.ObjectiveThe aim of this study is to understand the causal impact of US hospital telehealth adoption or discontinuation on hospital performance from 2016 to 2018.MethodsWe analyzed impacts of telehealth adoption or discontinuation by US hospitals on emergency department visits, total ambulatory visits (minus emergency department visits), outpatient services revenue, total facility expenses, and total hospital revenue for the 2016-2018 period. We specifically focused on performance effects for hospitals that switched from not having telehealth to adopting telehealth, or vice versa, during the 2016-2018 period, thus exploiting 2 quasi-natural experiments. We applied a difference-in-differences research design to each of the 2 main analyses. We compared hospitals that have made a telehealth change to groups of hospitals with similar characteristics that did not make a telehealth change, which established a counterfactual. To appropriately match hospitals between treatment and control groups, we applied propensity score matching. Our primary data were from the American Hospital Association Annual Survey and the Healthcare Cost Report Information System data. Several control variables were obtained from additional sources, including the Area Health Resource File and the Federal Communications Commission.ResultsWe found that telehealth adoption by US hospitals during the 2016-2018 period resulted in, on average, an increased number of total ambulatory visits (P=.008), increased total facility expenses (P<.001), and increased hospital revenue (P=.004) compared with the control group. We found that telehealth discontinuation during the same period resulted in, on average, decreased outpatient services revenue (P=.02) compared with the control group.ConclusionsOur findings suggest that telehealth adoption increases use but has mixed impacts on performance, given that cost and revenue increase. However, once telehealth is offered, removing it can have a negative impact on performance, implying that returning to prior performance levels, if telehealth is removed, may be challenging.

Association of women leaders in the C-suite with hospital performance

BackgroundWomen comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led...

Effects of affiliation network membership on hospital quality and financial performance.

To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay an annual fee for access to sponsor's operational and clinical resources-on clinical quality, patient experience ratings, and financial performance of affiliates and their competitors. Network membership data from press releases and websites of four sponsors (Mayo Clinic, Cleveland Clinic, MD Anderson, Memorial Sloan Kettering), American Hospital Association's Annual Survey, Centers for Medicare & Medicaid Services' Hospital Compare, and Healthcare Cost Report Information System, all for 2005-2016. We used a quasi-experimental design and estimated hospital-level regressions with hospital-fixed effects. Dependent variables were measures of clinical quality, patient experience, and financial performance. Independent variables included an indicator for affiliate versus nonaffiliate and fixed effects for hospital characteristics and year. To analyze effects on competitors, we repeated analyses by comparing hospitals in the same county as an affiliate to nonaffiliated, noncompetitor hospitals. Membership was obtained through press releases and network websites then linked across datasets by name and Medicare's identification number. Across networks, affiliates (N=199) experienced insignificant clinical quality changes but increased net income by $38,500 and operating margin by 6.6% (p values=0.01-0.08) compared to nonaffiliates. Multispecialty affiliates improved on no measures. Cancer-specific affiliates improved their net income ($96,900) and operating margin (3.6%; p-values < 0.05). Affiliates' competitors experienced mixed changes in clinical measures relative to hospitals without affiliates in market (p-value < 0.05) but no financial effects. Affiliation was not associated with patient experience ratings for affiliates nor competitors. Despite quality-focused missions, affiliation networks are not guaranteed to improve public measures of quality in affiliated hospitals, although hospitals in these communities improve financially. Future research should assess the conditions and mechanisms by which affiliation improves quality consistently and which forms of quality.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study.

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Methods for estimating the cost of treat-and-release emergency department visits.

To evaluate and compare approaches to estimating the service delivery cost of emergency department (ED) visits from total charge data only. The 2013-2017 Healthcare Cost and Utilization Project's (HCUP) State Emergency Department Databases (SEDD) and the Centers for Medicare and Medicaid Services Healthcare Cost Report Information System (HCRIS) public use files. Compare a baseline approach (requiring cost-center-level charge detail) and four alternative methods (relying on total charges only) for estimating ED visit costs. Estimation errors are calculated after applying each method to a sample of ED visits, treating estimates from the baseline approach as the "true" cost. Performance metrics are calculated at the visit and hospital levels. The charges, revenue center codes, and patient/hospital characteristics were extracted from the SEDD. Detailed costs and charges were extracted from HCRIS public use files. Baseline ("true") ED visit costs increased from $383 to $420 per visit between 2013 and 2017. Three methods performed comparatively well estimating mean cost per visit. The method using an overall cost-to-charge ratio (CCR) for all ancillary cost centers without regression adjustment (ANC-CCR) performed the worst, overestimating "true" costs by $63-$113 per visit. The other three methods, which used CCRs computed from selected cost centers, exhibited much smaller bias, with two of the methods yielding estimates within $2 of the "true" cost in 2017. Compared with ANC-CCR, the other three methods had more compact estimation error distributions. The estimated mean visit costs from all four methods have relatively small statistical variance, with 95% confidence intervals for mean cost in a hospital with 25,000 ED visits ranging between $4 and $7. When cost-center-level charge detail for ED visits is unavailable, alternative methods relying on total ED charges can estimate ED service costs for patient and hospital segments.

Using State Licensure Data to Assess North Carolina's Health Workforce COVID-19 Response Capacity.

BACKGROUND In the early months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages.METHOD Descriptive and cartographic analyses were conducted using licensure data held by the North Carolina Health Professions Data System to assess the supply of respiratory therapists, nurses, and critical care physicians in North Carolina. Licensure data were merged with population data and numbers of intensive care unit (ICU) beds drawn from the Centers for Medicare and Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).RESULTS The pandemic highlighted how critical data infrastructure is to public health infrastructure. Respiratory therapists and acute care, emergency, and critical care nurses were diffused broadly throughout the state, with higher concentrations in urban areas. Critical care physicians were primarily based in areas with academic health centers.LIMITATIONS Data were unavailable to capture the rapid changes in supply due to clinicians reentering or exiting the workforce. County-level analyses did not reflect individual, facility-level supply, which was needed to plan organizational responses.CONCLUSIONS Health care decision-makers in North Carolina were able to access information about the supply of clinicians critical to caring for COVID-19 patients due to the state's long-standing investments in health workforce data infrastructure. Ability to respond was made easier due to strong working relationships between the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, the North Carolina Area Health Education Centers Program, the health professional licensure boards, and state government health care agencies.

Associations between Medicaid expansion and nurse staffing ratios and hospital readmissions.

To examine the associations between Medicaid expansion and nurse staffing ratios and hospital-wide readmission rates. Secondary data from the 2011-2016 Healthcare Cost Report Information System, the American Hospital Association Annual Survey, and the Hospital Compare data. Difference-in-difference models are used to compare outcomes in hospitals located in states that expanded Medicaid with those located in nonexpansion states. The changes in nurse staffing ratios and hospital-wide readmission rates are calculated in each one of the postexpansion years (2014, 2015, and 2016), compared to pre-expansion. Results indicate that nurse staffing ratios increased, whereas hospital-wide readmission rates declined in expansion states relative to nonexpansion states. Nurse staffing ratios increased by 0.33, 0.42, and 0.46 registered nurses hours per adjusted patient days in 2014, 2015, and 2016 in hospitals located in expansion states, compared with hospitals in nonexpansion states after expansion. This increase was statistically significant (P<.001) in 2015 and 2016, but marginally significant (P=.016) in 2014. Hospital-wide readmission rates statistically significantly decreased by 9, 16, and 18 per 10000 patients (P<.001) in 2014, 2015, and 2016, respectively, in expansion vs nonexpansion states hospitals after expansion. Medicaid expansion was associated with gradually improved hospitals' nurse staffing ratios and hospital-wide readmission rates from 2014 through 2016. The continued monitoring of quality measures of hospitals can help assess the impact of Medicaid expansion over a longer period of time.

Variability between individual surgeons in route of hysterectomy for patients with endometrial cancer in Florida

ObjectivesMinimally invasive surgery (MIS) was designated as a quality measure for endometrial cancer in 2014. However, national database analyses demonstrate that laparotomy is still performed for this indication. This study aims to assess the route of hysterectomy performed by gynecologic surgeons who manage endometrial cancer in the state of Florida. Materials and methodsAll patients in Florida who were diagnosed with endometrial cancer (both ICD-9 Code 182.0 and ICD-10 Code C54.10), and who received a related surgical procedure from 2014 to 2016 were included. Eligible patients were identified using the Florida Inpatient Discharge Dataset, the Florida Ambulatory and Emergency Discharge Dataset, the Hospital Compare dataset, and the Healthcare Cost Report Information System. The primary surgeon was identified using their national provider identifier (NPI) number. Each surgeon's overall operative volume, MIS volume, and percentage of MIS procedures were collected. ResultsHysterectomy for endometrial cancer was performed in 6086 patients; 4959 (81.5%) underwent MIS and 1127 (18.5%) had an abdominal approach. Hysterectomy for endometrial cancer was performed by 368 providers in Florida (range of 2–244 surgeries). The percentage of MIS to total hysterectomies for providers who performed 1–10 cases was 72.1%; 11–25 cases was 40.9%; 26–100 cases was 80.1%; and more than 100 cases was 86.1%. Variation in operative route exists amongst low- and high-volume providers. ConclusionsStatewide databases can be used to identify surgical trends for policy purposes. These findings support the referral of patients with endometrial cancer to surgeons with high MIS volumes.

The Relationship between Health Information Technology Laboratory Tracking Systems and Hospital Financial Performance and Quality

The objective of this study is to explore the relationship between hospitals Health Information Technology (HIT), and financial and quality performance. The study merged the 2017 Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System, American Hospital Association Annual Survey, and two CMS Hospital Compare datasets. A total of 3002 hospitals were analyzed using multivariate analysis. We found that hospitals with laboratory tracking systems reported better financial performance on five financial performance measures. Policymakers should consider developing policies that facilitate exploration and adoption of various hospital HIT capabilities that measurably improves hospital quality of care.