Hospital Spending Research Articles

Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization.

To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries. Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services' 8-state Multi-Payer Advanced Primary Care Practice demonstration. Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00). Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.

Evaluating the economic effects of genomic sequencing of pathogens to prioritise hospital patients competing for isolation beds.

Objective This study compared the costs and patient movements of a new hospital protocol to discontinue contact precautions for patients with non-multiresistant methicillin-resistant Staphylococcus aureus (nmMRSA), based on whole-genome sequencing (WGS) of pathogens with current practice. Methods A hybrid simulation model was constructed and analysed over a 12-month time horizon. Six multidrug-resistant organisms and influenza were modelled concurrently where infected patients competed for isolation beds. Model inputs included pathogen incidence, resources for WGS, staff and contact precautions, hospital processes, room allocations and their associated costs. Data were sourced from aggregated records of patient admissions during 2017-18, clinical records and published reports. Results The WGS protocol resulted in 389 patients isolated (44% of current practice), 5223 'isolation bed days' (56%) and 268 closed-bed days (88%). Over 1 year, the mean (±s.d.) total cost for the WGS protocol was A$749243±126667; compared with current practice, the overall cost savings were A$690864±300464. Conclusion Using WGS to inform infection control teams of pathogen transmission averts patients from isolation rooms and reduces significant resources involved in implementing contact precautions. What is known about the topic? There are an estimated 265000 hospital-acquired infections (HAI) in Australia each year. WGS can accurately identify the genetic lineage among HAIs and determine transmission clusters that can help infection control staff manage patients. Economic appraisals are lacking to inform whether pathogen genomics services should be adopted within already-stretched hospital budgets. What does this paper add? An isolation protocol using pathogen genomics to provide additional information on the relatedness of a pathogen between colonised patients showed favourable results for healthcare costs and patient flow. Using WGS, in a confirmatory role, to discontinue certain patients from contact precautions and isolation rooms resulted in cost savings of A$690864 across 1 year for a single major hospital. What are the implications for practitioners? Using pathogen WGS services for infection control potentially curbs hospital spending, averts patient isolations and improves patient flow within hospitals.

The impact of global budget payment reform on systemic overuse in Maryland

BackgroundMedical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending. ObjectiveTo assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services. MethodsWe conducted a retrospective analysis of deidentified claims for 18–64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011–2013) and after implementation (2014–2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index. ResultsGlobal budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of −0.002 points (95%CI, −0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses. ConclusionsWe did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.

Impacts of Maryland's Global Budgets on Medicare and Commercial Spending and Utilization.

In 2014, Maryland incorporated global budgets into its long-running all-payer rate-setting model for hospitals in order to improve health, increase health care quality, and reduce spending. We used difference-in-differences models to estimate changes in Medicare and commercial insurance utilization and spending in Maryland relative to a hospital-based comparison group. We found slower growth in Medicare hospital spending in Maryland than in the comparison group 4.5 years after model implementation and for commercial plan members after 4 years. We identified reductions in Maryland Medicare admissions but no changes for commercial plan members, although their inpatient spending declined. Relative declines in emergency department and other hospital outpatient spending in Maryland drove slower Medicare hospital spending growth, saving $796 million. Our findings suggest global budgets reduce hospital spending and utilization but aligning incentives between hospital and nonhospital providers may be necessary to further reduce utilization and total spending.

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition

Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking. To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition. This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity. Using a difference-in-differences design, this study evaluated changes in net income, charges, charge to cost ratios, case mix index (a measure of reported illness burden), share of discharges for patients with Medicare or Medicaid coverage, discharges per year, and aggregate hospital quality measures associated with private equity acquisition through 3 years after acquisition, adjusted for case mix, hospital beds, calendar year, and adjustment for multiple hypothesis testing. In subgroup analyses, changes in outcomes for private equity-owned Hospital Corporation of America (HCA) hospitals and non-HCA hospitals relative to matched controls were assessed. Eight hospital income and use measures and 3 aggregate hospital quality measures were examined. Relative to 532 control hospitals, the 204 private equity-acquired hospitals showed a mean increase of $2 302 391 (95% CI, $956 660-$3 648 123; P = .009) in annual net income, an increase of $407 (95% CI, $296-$518; P < .001) in total charge per inpatient day, an increase of 0.61 (95% CI, 0.48-0.73; P < .001) in emergency department charge to cost ratio, an increase of 0.31 (95% CI, 0.26-0.37; P < .001) in total charge to cost ratio, an increase of 0.02 (95% CI, 0.01-0.02; P = .007) in case mix index, and a decrease of 0.96% (95% CI, 0.46%-1.45%; P = .002) in share of Medicare discharges. Medicaid's share of discharges (-0.16%; 95% CI, -0.86% to 0.53%; P > .99) and total hospital discharges (98; 95% CI, -54 to 250; P > .99) did not change differentially in a statistically significant manner. The aggregate quality score for acute myocardial infarction increased by 3.3% (95% CI, 1.6%-5.0%; P = .002), and the aggregate score for pneumonia increased by 2.9% (95% CI, 1.8%-3.9%; P < .001) in private equity-acquired hospitals relative to controls. The aggregate score for heart failure (1.3%; 95% CI, -0.2% to 2.7%; P = .92) did not differentially change in a statistically significant manner. In subgroup analyses, HCA hospitals showed similar findings to the entire sample. Among non-HCA hospitals, the only statistically significant relative changes were the increase in the emergency department charge to cost ratio (0.30; 95% CI, 0.12-0.48; P = .02) and the decrease in Medicare's share (-1.15%; 95% CI, -1.88% to -0.43%; P = .02). Non-HCA hospitals showed a decrease in the aggregate heart failure score (-3.3%; 95% CI, -5.3% to -1.3%; P = .01) and no statistically significant changes in the aggregate score for acute myocardial infarction (2.4%; 95% CI, -0.7% to 5.4%; P > .99) or pneumonia (0.2%; 95% CI, -1.4% to 1.7%; P > .99). Hospitals acquired by private equity were associated with larger increases in net income, charges, charge to cost ratios, and case mix index as well as with improvement in some quality measures after acquisition relative to nonacquired controls. Heterogeneity in some findings was observed between HCA and non-HCA hospitals.

Spillover Effects of the Comprehensive Care for Joint Replacement Program Among Non‐Medicare Patients

Research ObjectiveThrough the Comprehensive Care for Joint Replacement (CJR) Model, mandatory bundled payments for lower extremity joint replacement (LEJR) have produced 3‐4% episode cost savings with stable quality. Though CJR targets Medicare fee‐for‐service patients, it may prompt broad care delivery changes that “spill over” to other, non‐Medicare fee‐for‐service patients. Prior work demonstrating spillovers in CJR only evaluated utilization outcomes among a subset of hospitals, thereby compromising the program’s randomized design and failing to evaluate program‐wide utilization and spending spillovers. Therefore, we used more comprehensive data and an approach that preserved CJR’s randomized design to examine the impact of program participation on spillovers for commercially insured and Medicare Advantage patients.Study DesignWe used 2011‐2017 claims data from the Health Care Cost Institute (full claims of 25% of all insured US individuals younger than 65) to construct LEJR episodes for commercially insured and Medicare Advantage patients, and data from Medicare to identify markets (CJR markets) mandated to participate in CJR from April 2016 to December 2017. Leveraging the market‐level randomized design of CJR, we used hierarchical multivariable generalized linear models—adjusted for patient and market factors and incorporating time fixed effects and hospital and market random effects—to evaluate changes in LEJR episode spending, discharge to institutional postacute care, and quality outcomes (LEJR complication rate, readmissions, emergency department visits) in CJR versus non‐CJR markets. Additionally, we conducted stratified analyses by evaluating the association between CJR participation and outcomes for Medicare Advantage patients and commercially insured patients separately. To evaluate the robustness of our findings, we conducted sensitivity analyses that incorporated low volume CJR hospitals, hospital factors, and LEJR episodes with low index hospitalization spending. Statistical tests were 2‐tailed and significant at α=0.05.Population Studied418,016 Medicare Advantage or commercially insured patients receiving LEJR in 75 CJR or 121 non‐CJR markets.Principal FindingsThere were small differences in patient characteristics, including prior health care utilization, between CJR and non‐CJR markets. In adjusted analysis, patients who underwent joint replacement in CJR and non‐CJR markets did not differ with respect to episode spending (difference of ‐$157, 95% CI ‐$1,043 to $728, P = .73) or probability of discharge to institutional postacute care (difference of ‐1.1%, 95% CI ‐3.2% to 1.0 %, P = .31). Patients in CJR and non‐CJR markets also did not differ with respect to changes in quality outcomes. Stratified and sensitivity analyses yielded similar findings.ConclusionsThere was a lack of evidence supporting spillovers from CJR to patients insured through private health plans.Implications for Policy or PracticeUnlike voluntary programs, for which spillovers have been demonstrated, mandatory reforms may fail to create strong enough incentives for participants to enact broad care redesign and generate spillovers. Additionally, alternatives to the market‐level randomization used in CJR may be needed to address smaller sample sizes and increase the ability to detect meaningful spillovers. Both issues pose notable implications as policy makers consider whether and how to implement mandatory versus voluntary reforms in the future. Finally, this analysis also underscores the need to go beyond subgroup analyses and conduct program‐wide spillover evaluations, which generate the most policy‐ and practice‐relevant results.Primary Funding SourceLeonard Davis Institute of Health Economics.

Internações e custos hospitalares por quedas em idosos brasileiros

Objetivos: verificar o número e as causas de hospitalizações por quedas em idosos brasileiros, além dos gastos federais do Sistema Único de Saúde (SUS), no período de 2000 a 2018.Métodos: trata-se de um estudo ecológico, utilizando informações disponíveis na base de dados do Departamento de Informática do SUS. Foram coletados dados de idosos (≥60 anos) que internaram no SUS devido às quedas no período de 2000 a 2018 no Brasil. Extraíram-se o número de hospitalizações no País e nas regiões (Norte, Nordeste, Sul, Sudeste e Centro-Oeste), as causas das quedas (Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde – 10) e o valor de gastos federais. Para fins estatísticos, utilizou-se análise descritiva.Resultados: totalizaram-se 1,48 milhões de hospitalizações por quedas em idosos no Brasil, com uma taxa de 38,6 a cada 10 mil. As principais causas desses registros no DATASUS foram as “quedas sem especificações”, as “outras quedas no mesmo nível” e as “quedas no mesmo nível por escorregão, tropeção ou passos em falsos”. Em relação às localidades, os idosos pertencentes às regiões Sudeste (47,1), Sul (44,1) e Centro-Oeste (40,4) foram aqueles que apresentaram maiores medianas das taxas de hospitalizações por quedas no período analisado. Entretanto, o Nordeste (variação%=0,4), o Sul (variação%=0,2) e o Centro-Oeste (variação%=0,2) demonstraram maiores elevações desse indicador ao longo dos 18 anos, enquanto apenas a região Norte apresentou redução (variação%=-0,5). A mediana de gastos hospitalares federais (milhões) foi de R$135,58, variando de R$112,89 até R$194,98.Conclusões: houve aumento das taxas de hospitalizações por quedas em idosos no SUS em quase todas as unidades federativas. As causas mais frequentes foram as “quedas sem especificações”, as “outras quedas no mesmo nível” e as “quedas no mesmo nível por escorregão, tropeção ou passos em falsos”. Além disso, ocorreu elevação dos gastos hospitalares federais ao longo do período no País.

Influence of Government Price Regulation on the Price, Volume and Spending of Antibiotics in China: A Controlled Interrupted Time Series Study.

Background: Chinese government established maximum retail prices for antibiotics listed in China’s National Reimbursement List in February 2013. This study aimed to analyze the impact of pharmaceutical price regulation on the price, volume and spending of antibiotics in China. Methods: An interrupted time series design with comparison series was used to examine impacts of the policy changes on average daily cost, monthly hospital purchase volume and spending of the 11 price-regulated antibiotics and 40 priceunregulated antibiotics in 699 hospitals. One intervention point was applied to assess the impact of policy. Results: After government price regulation, compared to price-unregulated antibiotics, the average daily cost of the price-regulated group declined rapidly (β=-5.68, P<.001). The average hospital monthly purchase spending of priceregulated antibiotics also decreased rapidly (β=-0.49, P <.010) and a positive trend change (β=0.04, P<.001) in average hospital spending of price-unregulated antibiotics was found. Conclusion: Government regulation can reduce the prices and spending of price-regulated antibiotics. To control increasing expenditure, besides price caps regulation, factors determining drug utilization also need to be considered in policy designing.

Moving from Volume to Value with Hospital Funding Policies in Canada.

Canada's two most populous provinces are moving toward activity-based funding (ABF) of hospitals. Although ABF may encourage greater value by improving cost-efficiency, it may decrease value in other respects. To address this trade-off, many jurisdictions have implemented value-based payment programs that modify ABF payments based on hospital performance on other aspects of value, such as outcomes and patient experience. In this article, the design and implementation of two value-based programs are reviewed: Australia's Pricing for Safety and Quality Program and Medicare's Hospital Value-Based Purchasing Program. The contrasts of these programs highlight key questions facing provincial payers in Canada to increase value from hospital spending.

Association of State Medicaid Expansion With Hospital Community Benefit Spending

Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. State Medicaid expansion between 2011 and 2017. Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

National trends in prescription drug expenditures and projections for 2020.

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors. Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion. In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures. For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Hospital Quality-Review Spending and Patient Safety: A Longitudinal Analysis Using Instrumental Variables

Since the landmark Institute of Medicine’s (IOM’s) 2000 report first focused attention to the problem of the safety of inpatient care, it has been a priority of hospital staffs, administrators, and policymakers. Despite remarkable progress in the 20 years since the IOM report, there is still much unknown about how these improvements in safety have been achieved. Using a 12-year (2004 – 2015) panel of Florida acute-care general hospitals, we estimate the relationship between hospital quality-review (QR) spending and patient-safety outcomes, using a composite measure of patient safety (PSI-90) from the Agency for Healthcare Research and Quality. Our identification strategy to account for endogenous QR spending relies on exogeneity from within the hospital, in which we use staffing of non-acute ancillary services as instruments for QR spending. Estimation of hospital fixed effects (FE) and fixed effects with instrumental variables (FEIV) models both yield statistically significant and beneficial effects of QR spending on patient safety, with much larger effects in the FEIV model. From this model, we find, on average, that a 10 percent increase in QR spending is associated with a 2.5 percent (0.25 elasticity) beneficial decrease in patient-safety events (i.e. PSI-90). Broadly, this study represents a unique contribution to the literature by examining the direct relationship between hospital spending and quality.

SAT-156 Shorter Hospital Stays Are Not Associated with Increased Readmission or Complication Rates in Patients Undergoing Laparoscopic Adrenalectomies

Background: Traditionally, elective adrenalectomies have been performed as an inpatient procedure. However, the adoption of laparoscopic adrenalectomy as the gold standard has allowed for shorter postoperative stays. Our objective was to assess the safety of same-day discharge for patients undergoing laparoscopic adrenalectomy. Methods: A retrospective cohort study of patients who underwent laparoscopic adrenalectomy from 2011-2017 was conducted using The American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Demographic data was obtained. Multivariable logistic regression models to assess the association between length of stay and both postoperative complication rates and 30-day readmission rates were regressed on age, sex, race, comorbidities, functional status, postoperative diagnosis, and operative time. Statistical significance was defined as p<.05. Results: 5,611 unique patients who underwent a laparoscopic adrenalectomy were identified. 1,564 patients had a postoperative diagnosis of a pheochromocytoma (27.9%), 162 with Cushing’s syndrome (2.9%) and 210 (3.7%) had metastatic disease to the adrenal glands. The average postoperative length of stay was 2.4 days (SD=3.9). 93 patients (1.7%) were discharged on the same day as their surgery (POD0). 2,509 (44.7%) were discharged on postoperative day 1 (POD1), 1,558 (27.8%) on postoperative day 2 (POD2), and 1,451 (25.9%) after POD2. Longer hospital stays were predicted by male sex, non-white race, longer operating time, and postoperative complications in regression models.351 patients (6.26%) experienced a complication postoperatively. Complication rates were 3.23% for patients discharged on POD0, 1.67% for those discharged on POD1, 3.27% for those discharged on POD2, and 17.57% for those discharged after POD2 (p<.01). An increased risk of postoperative complications was also associated with male sex, impaired functional status and the presence of multiple comorbidities in regression models.290 patients (5.17%) experienced a readmission. Readmission rates were 4.30% for patients discharged on POD0, 3.67% for those discharged on POD1, 4.49% for those discharged on POD2, and 8.55% for those discharged after POD2 (p<.01). Multiple comorbidities, African American race, and post-operative complications were associated with higher readmission rates. Length of hospital stay was not associated with readmission rates in regression models. Conclusions: Readmission rates were not significantly different for patients discharged on POD0 than POD1 after a laparoscopic adrenalectomy. Readmission rates were higher for patients who had complications or multiple comorbidities. Therefore, low-risk patients with uncomplicated laparoscopic adrenalectomies can be considered for same day discharge to potentially reduce hospital spending and resource utilization.

Super-utilizers of Inpatient Care in an Obstetric Population [33N

INTRODUCTION: Super-utilizers (SUs) are patients who use a disproportionate amount of resources. Approximately 1–3% of adult patients account for 30% of hospital spending. Programs have been developed to improve healthcare delivery to SUs and decrease costs. Our objective was to create distribution curves of hospital charges (HC) and length of stay (LOS) in the obstetric population and characterize and compare SUs and typical utilizers (TUs). METHODS: We performed a retrospective cohort study of 500 patients at a tertiary center between 2012 and 2014. Data were collected 266 days prior to the estimated date of confinement (EDC) and up to 42 days post-delivery. Medical diagnoses, obstetric details, demographics, HC, and LOS were collected. RESULTS: Distribution curves for HC and LOS were positively skewed. SUs were defined as patients with charges greater than $75,000; they comprised 7% of patients (n=36) and accounted for 30% of charges. SUs averaged higher HC ($172,257 vs $30,524, P&lt;.05) and longer LOS (22.6 vs 3.2 days, P&lt;.05). They had earlier deliveries (34.5 vs 38.5 weeks, P&lt;.05), higher cesarean section rates (69% vs 35%, P&lt;.05), more chronic conditions (0.97% vs 0.48%, P&lt;.05), and pregnancy complications (2.08% vs 0.67%, P&lt;.05). The most common complications in SUs were preterm labor (33.3% vs 5.4%, P&lt;.05) and preterm premature rupture of membranes (25% vs 3.9%, P&lt;.05). CONCLUSION: There is unequal use of resources in the obstetric population and SUs are at risk for adverse outcomes. These data can guide our community to serve our most vulnerable patients through prevention, research, and care that specifically targets SUs.

Outcomes after Cholecystectomy in Patients with Sickle Cell Disease: Does Acuity of Presentation Play a Role?

Cholecystectomy is the most commonly performed procedure in sickle cell disease (SCD) patients, but outcomes after cholecystectomy have not been well studied. Our aim was to explore the characteristics and outcomes of cholecystectomy in patients with SCD compared with patients without SCD, and assess whether acuity of presentation played a role. Patients younger than age 35, with the primary diagnosis of gallbladder disease, who underwent cholecystectomy, were identified in the Nationwide Inpatient Sample (2005 to 2014). Patients were grouped into treatment groups by sickle cell status and acuity of surgery. Patient demographics, length of stay, hospital charges, and complications were evaluated. Descriptive and multivariate regression analyses were performed to compare these groups. There were 149,415 patients analyzed; 1,225 (0.82%) had SCD. SCD was associated with higher complication rates (2.69% vs 1.12%), longer lengths of stay (3 days vs 2 days), and higher median hospital charge ($29,170 vs $25,438) (all p < 0.01). Stratified by level of acuity, comparing the SCD group with the non-SCD group, higher complication rates were seen in the acute presentation group (3.92% vs 1.00%, p < 0.01), but were not demonstrated in the elective group (0.98% vs 1.95%, p= 0.114). SCD patients appear to have a longer length of stay, higher hospital spending, and increased complication rates compared with non-SCD patients undergoing cholecystectomy. This difference is pronounced among patients who underwent surgery in the acute setting. The data suggest that planned cholecystectomy may be beneficial in improving postoperative outcomes in SCD patients.

Nationwide Hospital Performance on Publicly Reported Episode Spending Measures.

Medicare has implemented strategies to improve value by containing hospital spending for episodes of care. Compared with payment models, publicly reported episode-based spending measures are underrecognized strategies. To provide the first nationwide description of hospitals' episode-based spending based on publicly reported Clinical Episode-Based Payment (CEBP) measures. We used 2017 Hospital Compare data to assess spending on six CEBPs among 1,778 hospitals. We examined spending variation and its drivers, correlation between CEBPs, and spending by cost performance categories (for individual CEBPs, below vs above average spending; for across-CEBP comparisons, high vs low vs mixed cost). We also compared hospital spending performance on CEBPs with a global Medicare Spending Per Beneficiary measure. Episode spending. Episode spending varied by CEBP type, with skilled nursing facility (SNF) care accounting for the majority of spending variation for procedural episodes but not for condition episodes. Across CEBPs, greater proportions of episode spending were attributed to SNF care at high-(18.1%) vs mixed-(10.7%) vs low-cost (9.2%) hospitals (P > .001). There was low within-hospital CEBP correlation and low correlation and concordance between hospitals' CEBP and Medicare Spending Per Beneficiary performance. Variation reduction and savings opportunities in SNF care for procedural episodes suggest that they may be better suited for existing payment models than condition episodes are. Spending performance was not hospital specific, which highlights the potential utility of episode spending measures beyond global measures.

The impact of the managed care backlash on health care spending

AbstractThe health spending slowdown associated with the managed care revolution in the 1990s suggests that managed care may have been successful in controlling health care spending. I exploit the passage of state regulation during the “managed care backlash” as well as geographic variation in managed care intensity to measure the impact of managed care on spending. I find that restricting managed care causes a large and significant increase in hospital spending, which cannot be explained by changes in hospital market concentration, other regulatory activity, and multiple other possible explanations. I also do not find effects of the backlash on mortality.

Association of Nonprofit Hospitals’ Charitable Activities With Unreimbursed Medicaid Care After Medicaid Expansion

In the United States, nonprofit hospitals receive tax-exempt status with the expectation that they provide a high level of benefit to local communities. Prior work has shown that Medicaid expansion reduced hospital spending on uncompensated care. To measure the association of tax-exempt hospital spending with community benefit and changes in uncompensated care after Medicaid expansion. This cohort study was performed using a difference-in-differences analysis (ie, a pre-post treatment-control design) to estimate changes in reported charitable categories associated with Medicaid expansion. Data from Internal Revenue Service form 990, Schedule H, tax filings for 2253 tax-exempt hospitals in the United States from 2012 to 2016 were used. Data were analyzed from June to November 2019. The proportion of the hospital's tax filing that spanned the period after Medicaid expansion. Hospital-reported spending on uncompensated care, unreimbursed Medicaid expenses, and other community benefit spending categories. Across 2253 hospitals, mean (SD) uncompensated care costs between 2012 and 2016 were $4.20 million ($8.80 million) and unreimbursed Medicaid expenses were $7.60 million ($18.62 million). Compared with tax-exempt hospitals in states that did not expand Medicaid, those in states that did expand Medicaid reported mean reductions in their provision of uncompensated care of $1.11 million (95% CI, $0.35 million to $1.87 million; P < .001), representing a mean change of -2% (95% CI, -6% to 2%; P < .001). These reductions have been offset by mean reported increases in the provision of unreimbursed Medicaid expenses of $1.63 million (95% CI, $0.31 million to $2.94 million; P = .02), representing a mean increase of 2% (95% CI, 1% to 4%; P = .01). Tax-exempt hospitals in states that expanded Medicaid reported no statistically significant mean increase in spending on other community benefit activities. In this study, large decreases in uncompensated care among tax-exempt hospitals associated with Medicaid expansion were not accompanied by increases in other reportable categories of community health benefit spending. Instead, they were accompanied by increased spending on unreimbursed Medicaid expenses.

Opting out of workers’ compensation: Non-subscription in Texas and its effects

Texas is the only state that does not mandate that employers carry workers’ compensation (WC) insurance coverage. In place of traditional WC, companies can choose to offer alternative “non-subscription” disability plans to workers. Little large-scale empirical research has studied the consequences of switching from traditional WC to non-subscription plans. We use a difference-in-differences estimator along with a novel machine learning approach to compare effects of switching to non-subscription plans for employees in Texas versus contemporaneously measured non-Texas-based employees for 25 large companies. Our results indicate that total medical payments dropped by roughly 40% from switching to non-subscription plans, consisting of reductions in hospital spending, physician spending, and other medical spending. Similarly, indemnity payments dropped by 70% and number of reported lost days dropped by 80%. Accumulating all sources of spending, we find that total expense associated with workplace injury fell by approximately 46% after switching to the non-subscription program.

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians.

Visual Abstract.Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Visual Abstract. Envisioning a Better U.S. Health Care System for All: A...