Payer Mix Research Articles

COVID-19 Pandemic Impact on Nursing Homes Financial Performance.

Nursing homes expressed concern about potential severe adverse financial outcomes of COVID-19, with worries extending to the possibility of some facilities facing closure. Maintaining a strong financial well-being is crucial, and there were concerns that the pandemic might have significantly impacted both expenses and income. This longitudinal study aimed to analyze the financial performance of nursing homes during COVID-19 pandemic. Specifically, we examined the impact of the pandemic on nursing home operating margins, operating revenue per resident day, and operating cost per resident day. The study utilized secondary data from various sources, including CMS Medicare cost reports, Brown University's Long Term Care Focus (LTCFocus), CMS Payroll-Based Journal, CMS Care Compare, Area Health Resource File, Provider Relief Fund distribution data, and CDC's NH COVID-19 public file. The sample consisted of 45 833 nursing home-year observations from 2018 to 2021. Fixed-effects regression analysis was employed to assess the impact of the pandemic on financial performance while controlling for various organizational and market characteristics. The study found that nursing homes' financial performance deteriorated during the COVID-19 pandemic. Operating margins decreased by approximately 4.3%, while operating costs per resident day increased by $26.51, outweighing the increase in operating revenue per resident day by about $17. Occupancy rates, payer mix, and staffing intensity were found to impact financial performance. The study highlights the significant financial impact of the COVID-19 pandemic on nursing homes. While nursing homes faced substantial financial strains, the findings offered lessons for the future, underscoring the need for nursing homes to improve the accuracy of their cost reports and enhance financial transparency and accountability.

Medicare skilled nursing facilities' occupancy and payer source: The moderating role of financial performance.

While extensive research has focused on patient outcomes in skilled nursing facilities, a critical gap remains in understanding factors influencing their managerial performance, particularly occupancy rates. This study examines the occupancy rates of skilled nursing facilities and assesses the significance of two important drivers of managerial performance that have not received sufficient attention-the influence of payer mix and total profit margin. Specifically, we focused on the role played by a nursing home's financial performance (as assessed by profit margin) in influencing the relationship between payer mix and occupancy rate among skilled nursing facilities. Data were extracted from the 2019 to 2020 Joint Annual Report of Nursing Homes for a sample of 612 skilled nursing facilities in Tennessee, USA. Regression analysis was performed by fitting a generalized estimating equation of occupancy rate. Compared to skilled nursing facilities in the lowest quartile of profit margin, for example, those in the highest quartile had approximately 18 percentage points higher occupancy rates per unit increase in resident days of care covered by traditional Medicare (β = 0.18, p = 0.0028). Similarly, skilled nursing facilities in the second highest quartile of profit margin had a higher occupancy rate by approximately 23 percentage points per unit increase in Medicare Advantage (β = 0.23, p = 0.0375) when compared to those in the lowest quartile of profit margin. Skilled nursing facilities with stronger financial performance generally have higher occupancy rates, particularly notable in relation to an upswing in payer sources such as traditional Medicare and Medicare Advantage, when compared to skilled nursing facilities with weaker profitability. Given the increasingly larger role of Medicare in long-term care funding, policymakers and nursing home managers may find it useful to consider our findings when evaluating opportunities to enhance managerial performance of skilled nursing facilities.

Hospital Care for Adult Patients with Congenital Heart Diseases

Objective: The ideal type of hospital to care for adult congenital heart disease (ACHD) patients is not well known. Hospital competitiveness, clinical volume and market structure can influence clinical outcomes. We sought to understand how hospital competitiveness affects clinical outcomes in ACHD patients in the era prior to the Adult Congenital Heart Association accreditation program. Methods: Patient discharges with ACHD diagnosis codes were filtered between 2006–2011 from an all-payer inpatient healthcare database. Hospital-level data was linked to market structure patient flow. A common measure of market concentration used to determine market competitiveness—the Herfindahl-Hirschman Index (HHI)—was stratified into: more competitive (HHI ≤25th percentile), moderately competitive (HHI 25th to <75th percentile), and less competitive (HHI ≥75th percentile) hospital. Any complication, home discharge and mortality were analyzed with clustered mixed effects logistic regression. The combined impact of HHI and any complication on mortality by interaction was assessed. Results: A total of 67,434 patient discharges were isolated. More competitive hospitals discharged the least number of patients (N = 15,270, 22.6%) versus moderately competitive (N = 36,244, 53.7%) and less competitive (N = 15,920, 23.6%) hospitals. The adjusted odds of any complication or home discharge were not associated with hospital competitiveness strata. Compared to more competitive hospitals, mortality at moderately competitive hospitals (Adjusted Odds Ratio (AOR) 0.79, 95% CI: 0.66–0.94) and less competitive hospitals (AOR 0.79, 95% CI: 0.63–0.98) were lower (p = 0.025). Age, race, elective admission, transfer status, and payer mix were all significantly associated with adjusted odds of any complication, home discharge and mortality (p ≤ 0.05). Having any complication independently increased the adjusted odds of mortality more than 6-fold (p < 0.001), and this trend was independent of HHI strata. Failure to rescue an ACHD patient from mortality after having any complication is highest at less competitive hospitals. Sensitivity analysis which excluded the transfer status variable, showed that any complication (p = 0.047) and mortality (p = 0.01) were independently associated with HHI strata. Conclusions: Whether lower competition allow hospitals to focus more on quality of care is unknown. Hospital competitiveness and outcome seem to have an inverse trend relationship among ACHD patients. Since medical care is frequently provided away from the home area, hospital selection is an important issue for ACHD patients. Further research is needed to determine why competitiveness is linked to surgical outcomes in this population.

Number Needed to Treat Analyses of Zanubrutinib in Relapsed/Refractory Chronic Lymphocytic Leukaemia

Introduction: Chronic lymphocytic leukaemia (CLL) is the most common leukaemia type. In 2020, there were an estimated 207,463 people living with CLL, with an annual incidence of approximately 4.9 per 100,000 in the United States (US). Zanubrutinib is a Bruton tyrosine kinase inhibitor that is FDA-approved and an NCCN preferred and recommended treatment of CLL. In the phase 3 ALPINE trial (NCT03734016), zanubrutinib elicited a significantly higher overall response rate and significantly longer progression-free survival (PFS) than ibrutinib. This study aimed to compare zanubrutinib versus ibrutinib in Relapsed/Refractory (R/R) CLL by calculating the number needed to treat (NNT) to avoid one progression or death and associated incremental costs. Methods:A health-economic model was developed to evaluate the number of R/R CLL patients needed to be treated to avoid a progression or death from the US payer perspective. Payer blend was assumed with 40% Commercial and 60% Medicare payer mix. Clinical efficacy data were extracted from the ALPINE trial. Final analysis result of 24-month PFS (79.5% for zanubrutinib and 67.3% for ibrutinib) was used for the base-case analysis in the model. Treatment, adverse event management, other medical resource use, and subsequent treatment costs were considered in the model. The NNT, incremental cost per treated patient, and incremental cost per additional patient with progression or death were captured. Deterministic sensitivity analyses were conducted to assess parameter uncertainties and explore key model drivers. Scenario analyses were conducted to test the impact of different PFS estimates. Results: The base-case results fromthe NNT model showed that for every 8 patients treated with zanubrutinib, 1 event of progression or death would be avoided compared to using ibrutinib. The total costs per patient treated with zanubrutinib and ibrutinib are $370,558 and $430,150, respectively, with a cost savings of $59,593 associated with using zanubrutinib (Table). Drug costs and PFS have the greatest impact on the incremental cost per patient. Varying the PFS scenarios, including adjustment with drug interruption, COVID death, or treatment discontinuation, change the NNT from 8 to 12, and are associated with cost savings of $58,179 to $67,153 per zanubrutinib-treated patient in a 24-month time frame. Applying the model result to a hypothetical scenario of a clinical practice of 100 patients treated with zanubrutinib versus ibrutinib suggest that approximately 13 patients will avoid disease progression events or death. Conclusions: The NNT model suggests thatusing zanubrutinib to treat R/R CLL patients, compared to ibrutinib, will result in more favorable clinical and economic outcomes in the US.

Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership.

Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022. Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed. 526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001). Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.

Novel Lifestyle Medicine Virtual Referral Clinic: A Quality Improvement Initiative to Increase Value-Based Care

Lifestyle education is a key component of healthcare, particularly primary care. Multiple studies have shown that dedicated patient education on lifestyle topics, in addition to medication management, creates the most positive outcomes. Improving knowledge on health topics is critical for eliciting positive change in health behaviors. However, education takes time, and access to focused education outside of the office visit can be a challenge. We discuss here a quality improvement initiative to increase value-based care by utilizing telehealth to improve access to Lifestyle Medicine education during the COVID-19 pandemic. We focused on 4 primary objectives including creating a Lifestyle Medicine Virtual Referral Clinic (LMVRC) embedded within our Family Medicine Residency, determining payor mix of referred patients, utilizing a telehealth platform to provide lifestyle medicine education, and finally determining the influence of our services on patient’s perceived health. There were many key findings in the development, implementation, and evaluation of the LMVRC that could serve to assist others and our clinic in further development of lifestyle medicine education in the primary care setting. In our experience, a LMVRC embedded in a primary care setting proved to be an effective approach to provide access for patients and advancing value-based care.

FRI653 Hemoglobin A1C-testing Inertia: A Barrier Observed In A Digital Diabetes Ecosystem Study

Abstract Disclosure: N. Thingalaya: Employee; Self; Sanofi. D. Kerr: Advisory Board Member; Self; Sanofi, Novo Nordisk, Abbott Diabetes Care. Research Investigator; Self; Novo Nordisk, Abbott Diabetes Care. Other; Self; Glooko, Hi.Health, SNAQ. F. Lee: Employee; Self; Sanofi. K.M. Pantalone: Consulting Fee; Self; AstraZeneca, Bayer, Inc., Corcept Therapeutics, Diasome, Eli Lilly &amp; Company, Merck, Novo Nordisk, Sanofi. Research Investigator; Self; Bayer, Inc., Merck, Novo Nordisk, Twin Health. Speaker; Self; AstraZeneca, Corcept Therapeutics, Merck, Novo Nordisk. P. Potukuchi: Employee; Self; Sanofi. J. Unger: None. G. Grunberger: Speaker; Self; Eli Lilly &amp; Company, Abbott Diabetes. Introduction: For people living with type 2 diabetes (T2D), digital health interventions show promise in improving clinical outcomes. Dario Diabetes Solution (DDS) is an application that combines remote self-blood-glucose monitoring, data visualization, and disease education to facilitate behavior change. We designed a retrospective study (RS) to assess clinical effectiveness of DDS on patients with uncontrolled T2D. As clinicians continue to rely on monitoring hemoglobin A1C (A1C) to assess disease progression, this study design gave us insights into the prevalence of A1C-testing inertia in T2D. Methods: Data from DDS users, their A1C and electronic medical records (EMR) were analyzed. Adults with T2D receiving ≥1 diabetes medication, with A1C ≥7.0%, and not using a continuous glucose monitor between 01/01/2017 and 10/31/2021, were eligible for inclusion. Baseline (BL) period was 1 year before the index date, defined as first registration for DDS users or first claim date in the quarter for nonusers. The follow-up period was index date +180 days. Severity of illness was compared using Charlson Comorbidity Index (CCI) score, diabetes medication use, and other comorbidities, including mental health burden such as depression and antidepressant use. We identified test-strip use as a proxy for degree of self-care. By applying sequential 1:3 exact and propensity-score (PS) match methods, we identified 1,005 users and 1,160,825 nonusers at BL from a database linked to claims and EMR. Results: The exact and PS match methods used in the RS generated a well-matched external cohort, with CCI scores of 1.5, 51% of oral antidiabetic-only users, and 6% insulin-only users. There was a well-matched distribution of payer mix, depression, and use of antidepressants. There were 7% more users of test-strips in the nonuser groups (p=0.0026) compared with DDS users at BL. 43.3% of users (n=570) and 45.9% of nonusers (n=628,167; p=0.098) did not have A1C results at 6 months. Conclusion: These findings suggest that the frequency of A1C testing remains sub-standard in the United States. Over 40% of a population with uncontrolled T2D did not have A1C values at 6 months, regardless of their degree of self-care behavior. While not all sources of A1C values were captured, this study ensured comparable disease severity and access to care. A1C was not performed to clinical guideline recommendations in either group. Testing inertia should be further studied to improve implementation of routine A1C testing. Despite use of glycemic targets as measures by payers, frequency of A1C testing remains sub-standard, even among digital health users. Identifying specific barriers to A1C testing could help inform future strategies for digital health solutions, which may help to reduce the existing therapeutic inertia. Presentation: Friday, June 16, 2023

177 Utilization of Hospital Payor Mix as an Estimate for Socioeconomic Status in a National Database

177 Utilization of Hospital Payor Mix as an Estimate for Socioeconomic Status in a National Database

The impact of Medicaid expansion on mental health and substance use related inpatient visits.

Under the Affordable Care Act, many states expanded their Medicaid eligibility, allowing individuals living at or below 138% of the Federal Poverty Level to receive insurance coverage. As a result, forty states and the District of Columbia have expanded Medicaid to date. Although Medicaid expansion is expected to increase access to care in general, it is not evident if it has helped increase access to mental health and substance use-related healthcare, especially in inpatient settings. Therefore, this study examines the impact of Medicaid expansion on mental health and substance use- (MHSU) related inpatient visits and the variation in payer mix. This study utilizes state-level quarterly inpatient visit data from the Healthcare Cost and Utilization Project's Fast Stats Database from 2005 to 2019 and performs difference-in-differences regression analyses to compare MHSU-related inpatient visit data in expansion and non-expansion states for all visits and by payer. Analyses controlled for state-level socio-demographic and health policy variables. Findings indicate that Medicaid expansion did not significantly affect overall MHSU-related inpatient visits. However, Medicaid expansion was associated with 22.74% increase (P < 0.01; 95% CI: 17.76, 27.71) in the Medicaid share of MHSU-related inpatient visits, 18.31% reduction (P < 0.01; 95% CI: -22.54, -14.09) in the uninsured share of MHSU-related inpatient visits, and 4.42% reduction (P < 0.05; 95% CI: -7.83, -1.01) in the privately insured share of MHSU-related inpatient visits in expansion states compared with non-expansion states. Findings show that Medicaid expansion significantly affects the payer mix associated with MHSU-related inpatient visits while it has no significant impact on the overall MHSU-related inpatient visits.

An Electronic Health Record-Based Automated Self-Rescheduling Tool to Improve Patient Access: Retrospective Cohort Study.

In many large health centers, patients face long appointment wait times and difficulties accessing care. Last-minute cancellations and patient no-shows leave unfilled slots in a clinician's schedule, exacerbating delays in care from poor access. The mismatch between the supply of outpatient appointments and patient demand has led health systems to adopt many tools and strategies to minimize appointment no-show rates and fill open slots left by patient cancellations. We evaluated an electronic health record (EHR)-based self-scheduling tool, Fast Pass, at a large academic medical center to understand the impacts of the tool on the ability to fill cancelled appointment slots, patient access to earlier appointments, and clinical revenue from visits that may otherwise have gone unscheduled. In this retrospective cohort study, we extracted Fast Pass appointment offers and scheduling data, including patient demographics, from the EHR between June 18, 2022, and March 9, 2023. We analyzed the outcomes of Fast Pass offers (accepted, declined, expired, and unavailable) and the outcomes of scheduled appointments resulting from accepted Fast Pass offers (completed, canceled, and no-show). We stratified outcomes based on appointment specialty. For each specialty, the patient service revenue from appointments filled by Fast Pass was calculated using the visit slots filled, the payer mix of the appointments, and the contribution margin by payer. From June 18 to March 9, 2023, there were a total of 60,660 Fast Pass offers sent to patients for 21,978 available appointments. Of these offers, 6603 (11%) were accepted across all departments, and 5399 (8.9%) visits were completed. Patients were seen a median (IQR) of 14 (4-33) days sooner for their appointments. In a multivariate logistic regression model with primary outcome Fast Pass offer acceptance, patients who were aged 65 years or older (vs 20-40 years; P=.005 odds ratio [OR] 0.86, 95% CI 0.78-0.96), other ethnicity (vs White; P<.001, OR 0.84, 95% CI 0.77-0.91), primarily Chinese speakers (P<.001; OR 0.62, 95% CI 0.49-0.79), and other language speakers (vs English speakers; P=.001; OR 0.71, 95% CI 0.57-0.87) were less likely to accept an offer. Fast Pass added 2576 patient service hours to the clinical schedule, with a median (IQR) of 251 (216-322) hours per month. The estimated value of physician fees from these visits scheduled through 9 months of Fast Pass scheduling in professional fees at our institution was US $3 million. Self-scheduling tools that provide patients with an opportunity to schedule into cancelled or unfilled appointment slots have the potential to improve patient access and efficiently capture additional revenue from filling unfilled slots. The demographics of the patients accepting these offers suggest that such digital tools may exacerbate inequities in access.

Cost and value of office-based facial plastic and reconstructive surgery procedures.

This chapter will provide an overview of factors affecting the cost of office-based procedures in Facial Plastics and Reconstructive Surgery (FPRS), and will discuss the value of office-based interventions. An in-depth literature review was conducted using multiple primary and secondary sources. Literature from multiple disciplines was included in the review, including otolaryngology, anesthesiology, surgery, public health, and economics. A wide variety of procedures can be performed in an FPRS office. Large upfront costs to the office include laser, electrocautery and surgical equipment. These investments will yield an initial negative cost margin until sufficient case volume is achieved. It is often in the best interest of the patient to perform a procedure in-office and avoid the facility and anesthesia fees associated with a surgical center or hospital. Costs and reimbursements vary greatly across regions and facilities. Additionally, overall cost depends on payer mix, procedures performed, and productivity of the practice. The scarcity of literature on this topic as it applies specifically to FPRS indicates that further research is needed to elucidate the value of common facial plastics procedures in an office-based setting.

The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation

Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.

Navigating Access and Optimizing Medication Infusions in an Academic Medical Center: A Quality Improvement Study.

(1) Background: The rising prices of medical infusions have resulted in the increased utilization of policies for payors to manage costs. These policies can be disruptive to the continuity of care, and health systems should develop a systematic strategy to address market changes and prevent patient leakage. (2) Methods: A quality improvement study was conducted by an interdisciplinary workstream to assess the current state of infusion services in an academic medical center in the Midwest and to provide recommendations for immediate access improvement and long-term system planning. An organizational assessment of the value stream was completed, which analyzed the available infusion capacity, billing strategy, patient mix/volumes, payor mix, staffing levels, and current policies. The interventions implemented after developing the infusion system strategy were triaging patients to the appropriate site of care to increase infusion capacity and eliminating paper orders in one of the health system's Infusion Centers. (3) Results: Patients receiving medical infusions for oncologic conditions warrant unique considerations in evaluating the Infusion Center's efficiency due to the infusion regimen's length, complexity, and tolerability. The management of the payor site of care also poses a challenge for health systems to triage patients effectively without fragmenting care. (4) Conclusions: An organizational strategy around infusion services must include broad stakeholder representation to address the clinical, operational, and financial challenges to provide timely care to patients.

Biosimilar uptake and cost savings analysis before and after implementation of a pharmacist-driven substitution program within a National Community Oncology Network: One-year follow-up.

6516 Background: As of December 2022, 22 of the 40 biosimilar approvals in the United States, are used for the treatment of cancer or for the supportive care of patients with cancer. Our organization is a network of community oncology practices, representing 107 oncologists at 76 locations across 17 states. Because our network faces formulary selection and reimbursement challenges related to a diverse payor mix across multiple states, we sought to see the impact of utilizing regional clinical pharmacists (RCPs) to assist with selection of the most cost-effective biosimilar products. Methods: In October 2021, our network initiated an RCP-driven biosimilar substitution program, whereby the RCP acts as a liaison between providers and financial teams to evaluate existing drug orders and their financial impact. We previously presented data on the financial impact to payors and providers before and after implementation of the program from 4/1/2021 to 4/1/2022. This study evaluates the one-year results following program implementation. Additionally, outcomes related to biosimilar utilization as well as financial impacts to payors, patients, and providers were assessed. Payor savings is defined as the difference of the calculated 80% Medicare ASP+6 for the administered biosimilar compared to the originator; patient savings is defined as the difference of the calculated 20% Medicare ASP+6 co-insurance for the administered biosimilar compared to the originator; provider savings is defined as the difference between the invoiced cost of the biosimilar compared to the originator. Results: By the end of 2022, preferred product utilization was achieved for &gt;90% of bevacizumab, trastuzumab, and rituximab orders. Use of the preferred pegfilgrastim product increased from &lt;20% in 4/2021 to &gt;60% by 12/2022. Use of filgrastim biosimilar product increased from &lt;75% in 4/2021 to &gt;90% by 4/2022, then decreased to 55% by 12/2022 due to trending ASP. Payor preference prevented biosimilar switching in approximately 34% of cases. Conclusions: Use of institution-preferred biosimilar products increased across all agents in this study after implementation of the RCP-driven biosimilar substitution program, except for filgrastim. Significant cost savings were noted for payors, patients, and providers. Barriers to switching to institution-preferred products included non-medical switching requirements by payors, patient assistance and compassionate use programs, and patient and/or provider preferences. [Table: see text]

Racial equity in trauma injury: An unresolved enigma

BackgroundRacial disparities in healthcare have been attributed to socioeconomic inequalities while the relative risk (RR) of traumatic injury in people of color has yet to be described. MethodsDemographics of our patient population were compared to the population of our service area. The racial and ethnic identities of gunshot wound (GSW) and motor vehicle collision (MVC) patients were used to establish RR of traumatic injury adjusting for socioeconomic status defined by payor mix and geography. ResultsGSW assaults were more common in Blacks (59.1%) while self-inflicted GSWs were more common in Whites (46.2%). RR of having a GSW was 4.65 times greater (95% CI 4.03–5.37; p < 0.01) among Blacks than other populations. MVC patients were 36.8% Black, 26.6% White, and 32.6% Hispanic. Blacks had an increased risk of MVC compared to other races (RR 2.13; 95% CI 1.96–2.32; p < 0.01). The racial and ethnic identity of the patient was not a predictor of GSW or MVC mortality. ConclusionsIncreased risk of GSW and MVC was not correlated with local population demographics or socioeconomic status.

Comparison of Delivery of Care Before and During COVID-19 Within an Academic Outpatient Psychiatry Practice.

Introduction: The COVID-19 pandemic has challenged outpatient mental health clinics. This article compares care delivery and patient characteristics before and during the COVID-19 pandemic in outpatient mental health clinics within an academic health system. Methods: A retrospective cohort study was conducted in patients who received outpatient psychiatric services at two clinics (A and B). The investigators compared care delivery with patients with mental health conditions prepandemic (January 1-December 31, 2019) and midpandemic (January 1-December 31, 2020) periods. Care delivery was defined as the number and type of new and return visits (telehealth and face-to-face visits), patients with recorded measurement-based care (MBC) outcomes, and communication capability between patients and providers. Results: During the prepandemic period, 6,984 patients were seen in Clinics A and B, resulting in 57,629 visits. In the midpandemic period, 7,110 patients were served, resulting in 61,766 total visits. Medication management visits increased from 2019 to 2020; number of visits with documented outcome measures increased by 90% in Clinic A and 15% in Clinic B. The number of MyChart messages per patient increased more than twofold during the midpandemic period. The number of new visits with primary diagnosis of anxiety disorders increased in CY2020 and the number of visits with primary diagnosis of major depressive/mood disorders decreased in CY2020. Payor mix did not vary between the two periods although there was variability between payor mix at the two primary clinic locations. Discussion: The study suggests that there was no detrimental impact on access to care between the prepandemic and midpandemic periods within the health system. Mental health visits while pivoting to telehealth increased during the midpandemic period. Transition to telepsychiatry improved the ability to administer and document MBC.

247 Private equity acquisition of nursing homes and the impact on long stay residents and racial disparities in care outcomes

OBJECTIVES/GOALS: To investigate nursing homes (NHs) acquired by private equity (PE) firms and estimate the effect of PE NH acquisitions on NH care quality for NH residents and whether PE NH acquisitions exacerbate racial inequities in quality of care. METHODS/STUDY POPULATION: My research estimates the causal effect of NH PE acquisitions on NH access and quality of care for NH residents and whether acquisitions exacerbate racial disparities in NH care for about 115 PE-owned NHs in the US, measuring the quality of care at the facility survey year level, and using an array of NH-level data sources. I identified 115 PE-owned NHs (treatment group) and 665 non-PE-owned NHs between 2003 and 2010, using the Online Survey Certification and Reporting database to obtain facility characteristics. I compare facility characteristics (e.g., payer mix, staffing levels, and quality measures such as pressure ulcers, unexpected weight loss, acuity, and health deficiencies). I will then test whether effects differ by race, with hypotheses informed by Public Health Critical Race Praxis approach. RESULTS/ANTICIPATED RESULTS: Preliminary results show that staffing levels differ between PE and non-PE-owned NHs in a way that aligns with a shift in focus toward the Medicare population i.e. short stays. We also find that deficiencies increased in PE-owned NHs compared to non-PE-owned NHs. We expect that PE acquisitions may lead to slightly widening racial disparities in NH care quality. Results may show that PE-owned NHs have a higher share of low-rated, high-BIPOC facilities. In weak markets, PE-owned NHs may have a higher share of BIPOC residents compared to highly competitive markets. This is because PE managers may prioritize cost over quality by cutting services. However, since quality measures are self-reported, except for measures related to deficiencies, this predicted lower quality of care may not be evident in observed data. DISCUSSION/SIGNIFICANCE: Understanding how PE ownership impacts nursing home care quality for long-stay residents, especially those funded by Medicaid, can help develop intervention strategies to effectively mitigate racial inequities in NH care, as Medicaid funded NH residents are more likely to be Black, Indigenous, and people of color.

MP12-15 DISPARITIES IN PROSTATE CANCER SCREENING AND DIAGNOSIS AMONG PATIENTS WITH MEDICAID

You have accessJournal of UrologyCME1 Apr 2023MP12-15 DISPARITIES IN PROSTATE CANCER SCREENING AND DIAGNOSIS AMONG PATIENTS WITH MEDICAID Henry Gold, Andrew Stevens, Tasha Posid, Dairon Denis-Diaz, Hafsa Asif, Aliza Khuhro, and Shawn Dason Henry GoldHenry Gold More articles by this author , Andrew StevensAndrew Stevens More articles by this author , Tasha PosidTasha Posid More articles by this author , Dairon Denis-DiazDairon Denis-Diaz More articles by this author , Hafsa AsifHafsa Asif More articles by this author , Aliza KhuhroAliza Khuhro More articles by this author , and Shawn DasonShawn Dason More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003227.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Medicaid patients with prostate cancer are four times more likely to present with metastatic disease and twice as likely to die of their cancer compared to patients with private insurance. Medicaid participation is related to other factors that limit healthcare access, including socioeconomic status (18,000/year individual income limit in Ohio) and race (48% of Medicaid enrollees are black in our county vs. 24% of population). We hypothesize that adverse prostate cancer outcomes in the Medicaid population relate to limited access to both PSA screening and evaluation of abnormal results. We reviewed our institutional triage process for patients referred for an abnormal prostate cancer screen with the goal of ensuring equitable intake processes based on payor status. METHODS: This is a retrospective study of patients who presented to our institution with an elevated PSA or an abnormal prostate exam from 2012-2021. Initial data on demographics, payor status, time to first appointment, screening history, and diagnostic testing are reported. Statistical analysis was performed with SPSS (IBM Inc.). Means were compared with the student’s t-test and logistic regression was used for correlative analysis with two-tailed p values <0.05 considered significant. RESULTS: Our initial analysis cohort included 149 patients who were predominantly Caucasian (58.0%) and had a mean age of 67.5 years (SD=9.11). Mean income based on home address zip code was $83,726 (SD=$30,488) and patients had a mean of 2.91 (SD=1.2) prior PSAs. We had a much lower proportion of patients with Medicaid status (6.7%) than expected based on our overall departmental payor mix and the size of the Medicaid population in our catchment area. Patients with Medicaid were almost 10 times more likely to not show up to their first appointment than those with other insurance types (p=0.014). Medicaid patients were also less likely to receive a biopsy (p=0.07) and had a lower number of PSA tests prior to referral (p=0.08). A zip code with lower mean income negatively predicted receipt of MRI prior to a biopsy (p=0.02). Times between referral, scheduling, and appointment were not impacted by payor status or zip code. CONCLUSIONS: Our data confirm disparities in several factors in our prostate cancer screening referrals known to relate to prostate cancer outcomes. To address this, we are implementing a Medicaid-focused program at our institution to improve on “No-show” rates and optimize guideline concordant care. Outreach to primary care providers with a large Medicaid patient population is also critical in promoting equity in PSA screening. Source of Funding: Ohio State University Patient Care Innovation Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e139 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Henry Gold More articles by this author Andrew Stevens More articles by this author Tasha Posid More articles by this author Dairon Denis-Diaz More articles by this author Hafsa Asif More articles by this author Aliza Khuhro More articles by this author Shawn Dason More articles by this author Expand All Advertisement PDF downloadLoading ...

Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits

The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings. The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and byphysician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care. In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations. This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation. Economic Analysis IV.

Severe Increase in Nursing Labor Cost and Effect on Surgical Department Financial Margins at an Academic, Tertiary Medical Center.

A pre-existing nationwide nursing shortage drastically worsened during the pandemic, causing a significant increase in nursing labor costs. We examined the financial impact of these changes on department of surgery financial margins. Operating room, inpatient, and outpatient financial metrics were analyzed. Monthly averages from a 14-month control cohort, January 2019 to February 2020 (pre-COVID-19), were compared with a 21-month cohort, March 2020 to November 2021 (COVID-19). True revenue and cost data from hospital accounting records, not estimates or administrative projections, were analyzed. Statistics were performed with standard Student's t -test and the Anderson-Darling normality test. Monthly surgical nursing costs increased significantly, with concomitant significant decreases in departmental contribution to margin. No significant change was observed in case volume per month, length of stay per case, or surgical acuity, as standardized by the US Centers for Medicare & Medicaid Services Case Mix Index. To obviate insurance payor mix as a variable and standardize cost data, surgical nursing expense per relative value unit was analyzed, demonstrating a significant increase. Hospital-wide agency nursing costs increased from $5.1 to $13.5 million per month (+165%) in 2021. Our results demonstrate a significant increase in surgical nursing labor costs with a resultant erosion of department of surgery financial margins. Use of real-time accounting data instead of commonly touted administrative approximations or Medicare projections increases both the accuracy and generalizability of the data. The long-term impact of both direct costs from supply chain interruption and indirect costs, such as limited operating room and ICU access, will require further study. Clearly this ominous trend is not viable, and fiscal recovery will require sustained, strategic workforce allocation.