Medicare Severity Diagnosis-Related Group Research Articles

Reconsidering the Affordable Care Act's Restrictions on Physician-Owned Hospitals: Analysis of CMS Data on Total Hip and Knee Arthroplasty.

Concerns about financial incentives and increased costs prompted legislation limiting the expansion of physician-owned hospitals in 2010. Supporters of physician-owned hospitals argue that they improve the value of care by improving quality and reducing costs. The purpose of the present study was to determine whether physician-owned and non-physician-owned hospitals differ in terms of costs, outcomes, and patient satisfaction in the setting of total hip arthroplasty (THA) and total knee arthroplasty (TKA). With use of the U.S. Centers for Medicare & Medicaid Services (CMS) Inpatient Charge Data, we identified 45 physician-owned and 2,657 non-physician-owned hospitals that performed ≥11 primary TKA and THA procedures in 2014. Cost data, patient-satisfaction scores, and risk-adjusted complication and 30-day readmission scores for knee and hip arthroplasty patients were obtained from the multiyear CMS Hospital Compare database. Physician-owned hospitals received lower mean Medicare payments than did non-physician-owned hospitals for THA and TKA procedures ($11,106 compared with $12,699; p = 0.002). While the 30-day readmission score did not differ significantly between the 2 types of hospitals (4.48 compared with 4.62 for physician-owned and non-physician-owned, respectively; p = 0.104), physician-owned hospitals had a lower risk-adjusted complication score (2.83 compared with 3.04; p = 0.015). Physician-owned hospitals outperformed non-physician-owned hospitals in all patient-satisfaction categories, including mean linear scores for recommending the hospital (93.9 compared with 87.9; p < 0.001) and overall hospital rating (93.4 compared with 88.4; p < 0.001). When controlling for hospital demographic variables, status as a non-physician-owned hospital was an independent risk factor for being in the upper quartile of all inpatient payments for Medicare Severity-Diagnosis Related Group (MS-DRG) 470 (odds ratio, 3.317; 95% confidence interval, 1.174 to 9.371; p = 0.024), which may be because of a difference in CMS payment methodology. Our findings suggest that physician-owned hospitals are associated with lower mean Medicare costs, fewer complications, and higher patient satisfaction following THA and TKA than non-physician-owned hospitals. Policymakers should consider these data when debating the current moratorium on physician-owned hospital expansion. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Enriching Medicare Severity-Diagnosis Related Group (MS-DRG) Payments for better Service to inpatients using ANFIS

Enriching Medicare Severity-Diagnosis Related Group (MS-DRG) Payments for better Service to inpatients using ANFIS

Similar Cost Savings of Bundled Payment Initiatives Applied to Lower Extremity Total Joint Arthroplasty Can Be Achieved Applying Both Models 2 and 3

BackgroundIn an effort to control cost and increase value, Medicare is transitioning from fee-for-service to value-based alternative payment models (APMs). The Bundled Payments for Care Improvement (BPCI) initiative represents one such voluntary APM. BPCI offers four different bundling options: model 1 covers all Diagnosis Related Groups (DRGs) and Models 2–4 cover 48 clinical episodes, including 186 separate DRGs.Questions/PurposesThe purpose of this investigation is to analyze and compare the cost savings achieved by two different BPCI program participants, provider A and provider B, enrolled in different models of BPCI (Models 2 and 3) for lower extremity joint replacements (LEJRs).MethodsWe analyzed the BPCI cost savings for Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 (lower extremity joint replacement) of two different BPCI program participants. One (provider A) participated in Model 2 while the other (provider B) participated in Model 3. Retrospective payments were based upon savings generated by decreased actual expenses reconciled against target pricing for the episode of care in Models 2 and 3.ResultsThe Model 2 participant reduced the average cost of all episodes by 18.45%, with all of the savings occurring in the post acute phase. The Model 3 participant reduced episode costs by 16.73%.ConclusionBoth BPCI providers achieved similar cost savings despite participating in different BPCI models. These cost savings all occurred in the post acute setting. The Model 2 provider achieved post acute savings through decreasing overall discharges to institutional post acute care (PAC) providers and decreasing readmissions, while the Model 3 provider decreased costs largely by decreasing the LOS for the institutional PAC providers and decreasing readmissions.

The readmission rates in patients with versus those without diabetes mellitus at an urban teaching hospital

ObjectiveWe examined the 30-day hospital readmission rates and their association with the admission diagnosis and the length of stay (LOS) in patients with diabetes versus those without diabetes mellitus (DM) in an urban teaching hospital. MethodsIn this retrospective study, we compared the 30-day readmission rates in patients with DM (n=16,266) versus those without DM (n=86,428) at an urban teaching hospital between January 1, 2013, and September 30, 2015. In individuals with a secondary diagnosis of DM, we analyzed the relationship between readmission rates and the ten most common Medicare Severity Diagnosis Related Groups (MS-DRGs). Additionally, we examined the relationship between the LOS and readmission rates in patients with diabetes and those without DM. ResultsThe 30-day readmission rates adjusted for age and gender were higher in patients with DM compared to those without DM (15.3% vs. 8.4%, respectively, <0.001). The increased risk of readmissions was present both in patients with a primary or a secondary diagnosis of DM. For the secondary diagnosis of DM, statistically significant difference was present for two out of the ten most common DRGs (DRG # 313 [chest pain], and # 392 [esophagitis, gastroenteritis, and miscellaneous digestive disorders], p=0.045 and 0.009, respectively). There was a direct correlation between LOS and readmission rates in both patients with diabetes and those without DM (p<0.001 for both). ConclusionsThe 30-day readmission rates are higher in patients with DM compared to patients without DM. DM is an independent risk factor for hospital readmissions. The readmission rates correlate directly with LOS in both patients with diabetes and those without DM.

Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative.

In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.

Development of Novel Formulas to Determine Hospital and Pharmacy Opportunities to Reduce Extended Length of Stay

Background: Hospital length of stay (LOS) is an important measure to determine resource utilization and efficiency of care for inpatients. No existing objective methodology is available to determine where and how pharmacy departments can have maximal impact on reducing extended LOS. Objective: An objective methodology to guide decisions by hospital pharmacy departments on reducing extended LOS is described. Methods: University of North Carolina Medical Center’s LOS was compared to hospitals with similar inpatient bed size and case mix index. Objective methodology using pharmacy intensity weight, LOS index, and relative number of cases overall and by hospital service was developed to identify targets of impacting LOS for a pharmacy department. Results: The novel Pharmacy Opportunity Length of Stay (POLOS) formula was developed to prioritize each Medicare Severity Diagnosis Related Group (MSDRG) based on the overall impact pharmacy can have on reducing extended LOS at an individual institution. An additional novel formula, Service Specific POLOS (SSPOLOS), was created to strategically target hospital services, as opposed to MSDRGs, allowing for effective deployment of targeted pharmacy interventions to decrease extended LOS. Conclusion: POLOS and SSPOLOS are novel formulas to guide pharmacy departments in objectively prioritizing and targeting resources to reduce extended LOS. The novel formulas can be used to quantify LOS performance at the hospital and pharmacy specific levels, in addition to providing a hospital service approach to launch LOS initiatives at health care institutions. To our knowledge, this represents the first opportunity for hospital pharmacy departments to objectively target and reduce extended LOS.

Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.

Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.

Differences in Hospital Billing for Total Joint Arthroplasty Based on Hospital Profit Status

BackgroundRegional variations in hospital billing for total joint arthroplasty (TJA) have been reported. It is not clear whether differences exist in hospital charges for TJA based on hospital profit status. MethodsData from the Centers for Medicare and Medicaid Services on Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 (TJA with comorbidity) and 470 (TJA without comorbidity) for fiscal year 2011 were analyzed. Differences in hospital charges and payments were investigated based on hospital profit status (nonprofit, government, and proprietary). Generalized estimating equations determined differences in charges and reimbursement between hospital types controlling for census region, MS-DRG, and number of discharges. ResultsSignificant differences in billing between institutions existed with median average hospital charges for nonprofit, government, and proprietary institutions being $70,514.30, $73,540.99, and $113,203.77 (P < .0001), respectively, for DRG 469 and $45,363.95, $44,956.57, and $62,715.39 (P < .0001), respectively, for DRG 470. Median average Centers for Medicare and Medicaid Services payments for nonprofit, government, and proprietary institutions for DRG 469 were $22,334.34, $21,346.65, and $21,281.30 (P = .017), respectively, and $14,461.95, $14,466.04, and $13,733.62 (P < .0001), respectively, for DRG 470. Multivariate analyses indicate that nonprofit hospitals charge 5% more (P = .021) and receive 3% less (P = .011) reimbursement than government hospitals. Proprietary hospitals charge 34% more (P < .0001) and receive 7% less (P < .0001) reimbursement than government hospitals. ConclusionSignificant differences in hospital charges based on institution profit status were found, with proprietary institutions charging significantly more than nonprofit and government institutions. However, proprietary institutions had the lowest median average reimbursement.

The Relative Importance of Post-Acute Care and Readmissions for Post-Discharge Spending.

To understand what patterns of health care use are associated with higher post-hospitalization spending. Medicare hospital, skilled nursing, inpatient rehabilitation, and home health agency claims, and Medicare enrollment data from 2007 and 2008. For 10 common inpatient conditions, we calculated variation across hospitals in price-standardized and case mix-adjusted Medicare spending in the 30days following hospital discharge. We estimated the fraction of spending differences between low- and high-spending hospitals attributable to readmissions versus post-acute care, and within post-acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use. We identified index hospital claims and examined hospital and post-acute care occurring within a 30-day period following hospital discharge. For each Medicare Severity Diagnosis-Related Group (MS-DRG) at each hospital, we calculated average price-standardized Medicare payments for readmissions, SNFs, IRFs, and post-acute care overall (also including home health agencies and long-term care hospitals). There was extensive variation across hospitals in Medicare spending in the 30days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS-DRGs. The proportion of differences attributable to readmissions versus post-acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post-acute care spending. There was also variation in the relative importance of the type of post-acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in post-acute care spending In contrast, for pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post-acute spending. Through initiatives such as bundled payment, hospitals are financially responsible for spending in the post-hospitalization period. The key driver of variation in post-hospitalization spending varied greatly across conditions. For some conditions, the key driver was having a readmission, for others it was whether patients receive any post-acute care, and for others the key driver was the type of post-acute care. These findings may help hospitals implement strategies to reduce post-discharge spending.

National characteristics and predictors of neurologic 30-day readmissions.

To examine national 30-day readmission rates for patients hospitalized with neurologic disorders. Using the University HealthSystem Consortium (UHC) database, we identified 554,399 index neurologic admissions from October 2011 through January 2015. We collected information regarding age, race, insurance payer, Medicare severity diagnosis-related group, and severity of illness. We examined readmission by diagnosis and performed multivariable logistic regression to determine predictors of readmission. The unplanned readmission rate was 11.0%. Rates of unplanned readmission were highest for patients with peripheral nerve disorders (21.9%), CNS neoplasms (21.0%), nonhypertensive encephalopathy (15.5%), arterial stenosis (15.4%), and bacterial CNS infections (14.5%). In multivariable analysis, higher severity of illness and public health insurance coverage predicted higher rates of 30-day readmission. We found significant variation in readmission rates for different neurologic disorders. These data provide insight into management of neurologic disease nationally, offering policymakers realistic goals for standards of care and challenging health care providers to develop systems-based solutions that will improve transitions of care for those at highest risk of readmission with neurologic disease.

Hospital Readmission Following Discharge From Inpatient Rehabilitation for Older Adults With Debility.

Debility accounts for 10% of inpatient rehabilitation cases among Medicare beneficiaries. Debility has the highest 30-day readmission rate among 6 impairment groups most commonly admitted to inpatient rehabilitation. The purpose of this study was to examine rates, temporal distribution, and factors associated with hospital readmission for patients with debility up to 90 days following discharge from inpatient rehabilitation. A retrospective cohort study was conducted using records for 45,424 Medicare fee-for-service beneficiaries with debility discharged to community from 1,199 facilities during 2006-2009. Cox proportional hazard regression models were used to estimate hazard ratios for readmission. Schoenfeld residuals were examined to identify covariate-time interactions. Factor-time interactions were included in the full model for Functional Independence Measure (FIM) discharge motor functional status, comorbidity tier, and chronic pulmonary disease. Most prevalent reasons for readmission were summarized by Medicare severity diagnosis related groups. Hospital readmission rates for patients with debility were 19% for 30 days and 34% for 90 days. The highest readmission count occurred on day 3 after discharge, and 56% of readmissions occurred within 30 days. A higher FIM discharge motor rating was associated with lower hazard for readmissions prior to 60 days (30-day hazard ratio=0.987; 95% confidence interval=0.986, 0.989). Comorbidities with hazard ratios >1.0 included comorbidity tier and 11 Elixhauser conditions, 3 of which (heart failure, renal failure, and chronic pulmonary disease) were among the most prevalent reasons for readmission. Analysis of Medicare data permitted only use of variables reported for administrative purposes. Comorbidity data were analyzed only for inpatient diagnoses. One-third of patients were readmitted to acute hospitals within 90 days following rehabilitation for debility. Protective effect of greater motor function was diminished by 60 days after discharge from inpatient rehabilitation.

Opioid Medication Practices Observed in Chronic Pain Patients Presenting for All-Causes to Emergency Departments: Prevalence and Impact on Health Care Outcomes.

Chronic pain is a significant health problem that affects an estimated 100 million American adults (aged ≥ 18 years). Chronic pain affects more individuals than heart disease, stroke, diabetes, and cancer combined. Chronic pain sufferers cost up to $635 billion annually in medical treatment and lost productivity. Opioids are commonly used to treat chronic pain, but their metabolic interactions with concurrently prescribed medications for concomitant disease burdens can affect potency and efficacy of pain therapy. Additionally, misuse of short-acting opioids (SAOs) for chronic pain versus breakthrough pain can create gaps in pain relief. These potentially suboptimal prescribing practices may contribute to the high economic impact associated with chronic pain. To examine the prevalence of suboptimal opioid therapy and the associated health care costs resulting from these prescribing practices in real-world patients presenting for all-causes to the emergency department (ED). This retrospective observational database cohort analysis used the linked Premier-Optum database and included patients with ED visits from 2006 to 2010 having ≥ 60 days supply of opioids in the 75 days prior to the visit. Suboptimal prescribing practices were identified as patients with (a) drug-drug exposures (DDEs), defined as cytochrome P-450 (CYP-450)-metabolized opioids prescribed concurrently with CYP-450 inhibitors or inducers and/or (b) monotherapy with SAOs. Comorbid conditions and principal diagnoses were documented. Readmission rates to the ED and hospital within 72 hours as well as ≤ 30, ≤ 45, ≤ 60, and ≤ 90 days were computed. Total costs for health care were calculated, and reimbursement rates were normalized using 2011 Medicare severity diagnosis-related group (MS-DRG) and CPT-4 information. Nonparametric bootstrapping to adjust for patient comorbidities was applied to cost data. Of the 9,214 patients identified with chronic pain, potentially suboptimal medication practices prior to the index ED visit were found for 8,539 (92.6%) patients. These appeared to be corrected in 345 (4.0%) patients before leaving the ED. Of 675 (7.3%) patients without prior DDE or exclusive use of SAOs, 345 (51.1%) patients were discharged with one of these. Of the 8,352 patients who left the ED with DDE or exclusive use of SAOs, 1,525 (18.3%) left with a DDE without exclusive SAO use; 4,812 (57.6%) left with both DDE and exclusive SAO use; and 2,015 (24.1%) left with only exclusive SAO use. Only 862 (9.3%) patients from the entire cohort left the ED without DDE or exclusive SAO use. Patients identified with suboptimal opioid use were aged 50 ± 13.5 years and were predominantly female (64.0%). Hypertension (44.0%), fluid and electrolyte disorders (32.7%), chronic pulmonary disease (22.8%), depression (19.6%), diabetes without chronic complications (16.2%), and drug abuse (15.6%) were the most prevalent comorbid conditions identified. The most prevalent principal diagnoses involved symptoms and signs of ill-defined conditions (36.5%), injury and poisoning (18.2%), and diseases of the musculoskeletal system (13.2%). The majority of revisits to the ED and hospital admissions occurred within 72 hours (73.6%) of the index visit and within 30 days (70%), respectively. When adjusted total costs were compared for all patients whose opioid use included DDE versus those without, a significantly greater cost (P less than 0.05) was observed at every time period except ≤ 72 hours. Respective mean increases in costs were $581, $689, $773, and $1,275 at 30, 45, 60, and 90 days. Exclusive SAO use with or without DDE resulted in a significant increase (P less than 0.05) in mean costs at all times: $214 at 72 hours; $836 at 30 days; $1,023 at 45 days; $1,022 at 60 days; and $1,536 at 90 days. This study identified potentially suboptimal opioid prescribing practices in a real-world population presenting for all-causes to the ED. The observed rate of ED revisits and inpatient admissions in these patients was associated with increased health care costs. These findings suggest that the ED has the future potential to serve as an ideal setting to identify and correct such practices, thereby improving patient care and reducing resource use and beneficiary costs.

Comparative analysis of Medicare discharges following an acute inpatient hospitalization under MS-DRG 207

Purpose – The purpose of this study is to conduct a comparative analysis of the Medicare patients discharged to a long-term (acute) care hospitals (LTCH), skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) following an acute inpatient hospitalization under Medicare-severity diagnosis-related group (MS-DRG) 207. The likelihood of discharge by provider type was also examined to determine criteria informing patient discharge to a LTCH, SNF or IRF for treatment. Design/methodology/approach – Retrospective cohort study, based on secondary data analysis, utilizing Medicare Provider Analysis and Review (MedPAR) File data collected by Centers for Medicare &amp; Medicaid Services for fiscal year 2011, October 1, 2010, through September 30, 2011. Findings – Numerous analyses were conducted upon those patients discharged to a LTCH, SNF or IRF following an acute inpatient hospitalization under MS-DRG 207. Concerning those patients discharged to LTCHs, patients were not significantly older, did not have the highest length of stay and had comparable diagnoses and diagnosis counts to those discharged to SNFs or IRFs. However, costs were significantly higher among discharges to LTCHs. Multinomial logistic regression analyses also indicated numerous associations between certain variables and discharge location. Originality/value – With the aging of the US population and increasing costs of rendering services, both the Medicare population and Medicare expenditures, already at their highest levels in the history of the program, are projected to rise going forward (The Boards of Trustees, 2012). As such, recent research has focused on Part A hospitals/facilities and the variations in costs submitted and payments received for treatment/services provided. This study aims to address whether patients discharged to LTCHs, which receive higher payment(s) as a result of serving a higher proportion of medically complex beneficiaries, are more medically complex than those discharged to SNFs/IRFs.

Hospitalization costs for acute myocardial infarction patients treated with percutaneous coronary intervention in the United States are substantially higher than Medicare payments.

Acute coronary syndromes account for half of all deaths secondary to cardiovascular disease and represent a significant economic burden in the United States. Therefore, assessing hospitalization costs relative to Medicare reimbursement for these patients is important in understanding the impact of these patients on hospitals. We hypothesized that hospitalization costs for acute myocardial infarction patients treated with percutaneous coronary intervention (PCI) were higher than their associated Medicare payments. Using the Nationwide Inpatient Sample, we evaluated hospitalization costs for patients treated with PCI from 2001 through 2009 by multiplying hospital charges by the group average cost-to-charge ratio for each patient's hospitalization. Primary end points examined were total hospital costs and trends over time, which were correlated with clinical outcomes and insurance payments. Costs were inflation adjusted with 2009 as the reference year. Median hospitalization costs of PCI increased from $15 889 (interquartile range [IQR] = $12 057-$21 204) in 2001 to $19 349 (IQR = $14 660-$26 282) in 2009. From 2004 to 2009, inflation-adjusted costs for PCI decreased at a rate of 0.3% per year. In 2009, a total of 265,531 patients received PCI for acute myocardial infarction. Of these, 143 654 were <65 years old, and 121 876 were ≥65 years old. Average 2009 Medicare payments ranged from $9303 to $17 500 depending on the Medicare Severity-Diagnosis Related Groups (MS-DRG) billed, leaving hospitals at a loss of anywhere from $4493 to $7940 per patient when comparing costs and reimbursements across all included MS-DRG codes. Hospitalization costs for patients treated with PCI have been stabilizing over the last few years; however, there still remains a significant disparity between Medicare reimbursements and hospitalization costs, which has potential implications on patient outcomes, quality of care, and hospital sustainability.

Association of the position of a hospital-acquired condition diagnosis code with changes in medicare severity diagnosis-related group assignment.

Incentives to improve quality include paying less for adverse events, including the Centers for Medicare and Medicaid Services' policy to not pay additionally for events classified as hospital-acquired conditions (HACs). This policy is controversial, as variable coding practices at hospitals may lead to differences in the inclusion and position of HACs in the list of codes used for Medicare Severity Diagnosis-Related Group (MS-DRG) assignment. Evaluate changes in MS-DRG assignment for patients with an HAC and test the association of the position of an HAC in the list of International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes with change in MS-DRG assignment. Retrospective analysis of patients discharged from hospital members of the University HealthSystem Consortium's Clinical Data Base between October 2007 and April 2008. Comparisons were made between the MS-DRG assigned when the HAC was not included in the list of ICD-9 diagnosis codes and the MS-DRG that would have been assigned had the HAC code been included in the assignment. Of the 7027 patients with an HAC, 13.8% changed MS-DRG assignment when the HAC was removed. An HAC in the second position versus third position or lower was associated with a 40-fold increase in the likelihood of MS-DRG change. The position of an HAC in the list of diagnosis codes, rather than the presence of an HAC, is associated with a change in MS-DRG assignment. HACs have little effect on reimbursement unless the HAC is in the second position and patients have minor severity of illness.

Effect of a medical toxicology admitting service on length of stay, cost, and mortality among inpatients discharged with poisoning-related diagnoses.

There are no published studies that have compared quality outcomes of hospitalized poisoned patients primarily under the care of physician medical toxicologists to patients treated by non-toxicologists. We hypothesized that inpatients primarily cared for by medical toxicologists would exhibit shorter lengths of stay (LOS), lower costs, and decreased mortality. Patients discharged in 2010 and 2011 from seven hospitals within the same health care system and greater metropolitan area with Medicare severity diagnosis-related groups for "poisoning and toxic effects of drugs" with and without major comorbidities or complications (917 & 918, respectively) were identified from a Premier® database. The database contained severity-weighted comparisons between expected and observed outcomes for each patient. Outcome parameters were differences between expected and observed LOS, cost, and percent mortality. These were then compared among groups of patients primarily admitted and cared for by (1) medical toxicologists at one hospital (Banner Good Samaritan Medical Center, BGS), (2) non-toxicologists at BGS, and (3) non-toxicologists at six other hospitals. Records of 3,581 patients contained complete data for assessment of at least one outcome measure. Patients cared for by medical toxicologists experienced favorable differences in LOS, costs, and mortality compared with other patient groups (p < 0.001). If patients cared for by non-toxicologists had experienced similar differences in observed over expected values for LOS, cost, and mortality as those cared for by medical toxicologists, there would have been a median savings of 1,483 hospital days, $4.269 million, and a significant decrease in mortality during the 2-year study period. Differences between observed and expected LOS, cost, and mortality in patients primarily cared for by medical toxicologists were significantly better than in patients cared for by non-toxicologists, regardless of facility. These data suggest that significant reductions in patient hospital days, costs, and mortality are possible when medical toxicologists directly care for hospitalized patients.

Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.

The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Large Variance Seen in Medicare Payments for Gastrointestinal Bleeding

Purpose: In May 2013, Centers for Medicare and Medicaid Services (CMS) released the hospital charge and payment data for top 100 Medicare Severity Diagnosis Related Groups (MS-DRG) for the first time. This study evaluates variability in covered charges submitted by hospitals and CMS payments for gastrointestinal hemorrhage. Methods: MS-DRG is an aggregate of similar diagnoses, procedures and services during a hospital stay with sub-classifications - Major Complication/Comorbidity (MCC), Complication/ Comorbidity (CC) and Without-Complication/Comorbidity (w/o CC/MCC) ranging from most severe cases to cases with no significant conditions affecting severity or resource utilization. We selected DRGs of all 3 severity types (DRG 377, DRG 378, DRG 379 respectively) for gastrointestinal hemorrhage for all Medicare discharges in the year 2011. Descriptive statistics were used to analyze variations in DRG payments, submitted charges, and volumes based on geographical region and hospital ownership.FigureResults: Data from 2,494 acute care facilities were included. The highest number of discharges were in Florida (FL), California (CA), Texas (TX), New York (NY), and Illinois (IL) and the lowest were in Alaska (AK), Wyoming (WY), Vermont (VT), Montana (MT), and Idaho (ID). 48,398 discharges were DRG 377 with mean hospital charge of $46,459, and average Medicare payment of $12,730. The highest average payment was in AK ($20,419) compared to lowest average payment in AR ($10,335). 138,678 discharges were classified as DRG 378 with average hospital charge of $26,058 and average payment of $7,084. The highest average payment was in AK ($10,988) compared to the lowest average payment in AL ($5,864). 33,393 discharges were classified as DRG 379, with the mean hospital charge of $18,975, and average payment of $5,031. Highest average payment was in AK ($8,045) and the lowest was in Kansas ($4,180). County by county variability is seen in the attached graphic. Proprietary hospitals were noted to have maximum average charge but lowest average payments across DRGs. Conclusion: Significant state, county and ownership based cost variations exist within all MS-DRGs for for gastrointestinal bleeding. Future studies should focus on determining the cause of these variations and determining cost of care for specific MS-DRGs. Disclosure - Maged Rizk: Investor: Innowaiting (Dawazu LLC).

Impact of Hospital Variables on Case Mix Index as a Marker of Disease Severity

Case mix index (CMI) has become a standard indicator of hospital disease severity in the United States and internationally. However, CMI was designed to calculate hospital payments, not to track disease severity, and is highly dependent on documentation and coding accuracy. The authors evaluated whether CMI varied by characteristics affecting hospitals' disease severity (eg, trauma center or not). The authors also evaluated whether CMI was lower at public hospitals than private hospitals, given the diminished financial resources to support documentation enhancement at public hospitals. CMI data for a 14-year period from a large public database were analyzed longitudinally and cross-sectionally to define the impact of hospital variables on average CMI within and across hospital groups. Between 1996 and 2007, average CMI declined by 0.4% for public hospitals, while rising significantly for private for-profit (14%) and nonprofit (6%) hospitals. After the introduction of the Medicare Severity Diagnosis Related Group (MS-DRG) system in 2007, average CMI increased for all 3 hospital types but remained lowest in public vs. private for-profit or nonprofit hospitals (1.05 vs. 1.25 vs. 1.20; P<0.0001). By multivariate analysis, teaching hospitals, level 1 trauma centers, and larger hospitals had higher average CMI, consistent with a marker of disease severity, but only for private hospitals. Public hospitals had lower CMI across all subgroups. Although CMI had some characteristics of a disease severity marker, it was lower across all strata for public hospitals. Hence, caution is warranted when using CMI to adjust for disease severity across public vs. private hospitals.

Measuring Cardiac Waste

The authors developed 8 measures of waste associated with cardiac procedures to assist hospitals in comparing their performance with peer facilities. Measure selection was based on review of the research literature, clinical guidelines, and consultation with key stakeholders. Development and validation used the data from 261 hospitals in a split-sample design. Measures were risk adjusted using Premier's CareScience methodologies or mean peer value based on Medicare Severity Diagnosis-Related Group assignment. High variability was found in resource utilization across facilities. Validation of the measures using item-to-total correlations (range = 0.27-0.78), Cronbach α (.88), and Spearman rank correlation (0.92) showed high reliability and discriminatory power. Because of the level of variability observed among hospitals, this study suggests that there is opportunity for facilities to design successful waste reduction programs targeting cardiac-device procedures.