Payer Mix Research Articles

The impact of the Affordable Care Act on provision of endodontic services within a dental school setting in Oregon.

In January 2014 implementation of the Medicaid expansion of the Affordable Care Act (EACA) in Oregon increased the number of children and adults qualifying for the Oregon Health Plan (OHP). Simultaneously, dental care benefits for adult Medicaid members were restored in Oregon after a period of noncoverage. This study evaluated the impact of these changes on the receipt of endodontic services in the Graduate Endodontic Clinic (GEC) at Oregon Health & Science University. A retrospective electronic health records (EHRs) database review was conducted from July 2010 through June 2017, a seven-year period covering 3.5 years before (pre-EACA) and 3.5 years after (post-EACA) implementation of EACA. The number of completed anterior, premolar and molar non-surgical root canal therapies (NS-RCT) was retrieved from de-identified EHRs by targeting dental codes. Pre- and post-EACA frequencies were compared and analyzed by patient age [<21 years (children) versus adults], payer mix [OHP versus non-Medicaid (self-pay and private insurance)], and tooth type (anterior, premolar and molar) using Chi-square tests (P < 0.05). The number of procedures provided for patients covered by OHP post-EACA compared to pre-EACA was increased by 363 percent. There was an 18 percent decline in NS-RCT provided for non-OHP patients (P < 0.0001). Post-EACA increases in frequency applied to anterior, premolar, and molar NS-RCT (P < 0.0001), with the greatest increase in frequency post-EACA occurring for premolar NS-RCT procedures (666 percent). By eliminating barriers to care greater numbers of vulnerable people in Oregon sought and received endodontic services at the GEC.

The Financial Impact of the Affordable Care Act on a Level-1 Orthopedic Trauma Service.

To determine the impact of the Affordable Care Act (ACA) on professional fees and proportion of payer type for an orthopedic trauma service at a level-1 trauma center. We analyzed professional fee data and payer mix for the 18 months before and after implementation of the ACA. Data were collected for inpatients (IP) and outpatients (OP). We corrected for changes in patient volume between the 2-time periods by calculating average values per patient. Post ACA, we treated a higher percentage of patients with Medicaid and had a reduction in the percentage of uninsured/county payers. Collections for IPs decreased $75.49/patient and OPs decreased $0.10/patient. Our collection rate decreased 6% for IPs and 5% for OPs. In particular, Medicaid collections decreased by $180/IP, and $4/OP, and Medicare decreased by $61/IP and increased $5/OP post ACA, whereas contract collections increased by $140/IP and $20/OP. The changes in our own institution's insurance were mixed with decreases of $514/IP for partial risk and $735/IP for full-risk insurance and increases of $1/OP for partial risk, and $35/OP for full-risk insurance. Post ACA, we saw less patients, primarily in the OP setting. This shift was accompanied by a significant decrease in our collection rate; specifically, a decrease in the amount we collected per Medicaid patient-the category of payer that increased post ACA. The ACA did allow more uninsured patients access to medical care but was associated with lower IP and OP reimbursements.

Impact of Affordable Care Act-related insurance expansion policies on mortality and access to post-discharge care for trauma patients: an analysis of the National Trauma Data Bank.

Uninsured trauma patients have worse outcomes and worse access to post-discharge care that is critically important for recovery after injury. Little is known regarding the impact of the insurance coverage expansion policies of the Affordable Care Act (ACA), most notably state-level Medicaid expansion, on trauma patients. In this study, we examine the national impact of these policies on payer mix, inpatient mortality, and access to post-acute care for trauma patients. We used the 2011-2016 National Trauma Data Bank to evaluate for changes in insurance coverage among trauma patients 18-64 years old. Our pre-/post-expansion models defined 2011-2013 as the pre-policy period, 2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated changes in inpatient mortality and discharge disposition among the policy-eligible sample, we leveraged multivariable linear regression techniques to adjust for year-to-year variation in patient demographics, injury characteristics, and facility traits. We then examined the relationship between the magnitude of facility-level reductions in uninsured patients and access to post-acute care after policy implementation. We identified 1,656,469 patients meeting inclusion criteria between 2011 and 2016. The pre-policy uninsured rate of 23.4% fell by 5.9 percentage-points after coverage expansion (p < 0.001), with a corresponding 7.5 percentage-point increase in Medicaid coverage (p < 0.001). After policy implementation, there were no significant changes in inpatient mortality. However, there was a >30% relative increase in discharge to a post-acute care facility and a similar increase in discharge with home health services (p < 0.001 for both). The greatest gains in access to post-acute services were seen among facilities with the greatest reductions in their uninsured rate (p = 0.003). ACA-related coverage expansion policies, most notably Medicaid expansion, were associated with a >25% reduction in the uninsured rate among non-elderly adult trauma patients. Although no immediate impact on inpatient mortality was seen, insurance coverage expansion was associated with a higher proportion of patients receiving critically important post-discharge care. Epidemiological, level III.

152. Substance Use Screening, Brief Intervention, And Referral To Treatment (SBIRT) In Pediatric Practice: A Quality Improvement Project In The Maryland Adolescent And Young Adult Health Collaborative Improvement And Innovation Network

The Adolescent and Young Adult Health Collaborative Improvement and Innovation Network (AYAH CoIIN) is a national initiative, composed of states including Maryland, designed to improve adolescent preventive services. The Maryland AYAH CoIIN recognized that there is limited data on how pediatric practices in Maryland have integrated evidence-based practice models. The purpose of this Quality Improvement (QI) project was to evaluate the impact of an SBIRT (Screening, Brief Intervention & Referral to Treatment) training intervention on provider knowledge, confidence, adoption of a validated screen for substance use, delivery of a brief intervention, and screening for associated behaviors such as sexual activity. This project implemented the evidence-based SBIRT model of screening for adolescent substance use using the “CRAFFT” screening tool. A “Plan/Do/Study/Act” approach to QI was utilized. This human subjects’ approved project was conducted in a large 9-provider multidisciplinary pediatric practice serving a diverse patient population with a high Medicaid payer mix in a community with higher than national substance use. Prior to the intervention, no standardized screening tool for substance use was being used. To prepare the intervention, baseline data was collected and the CRAFFT was integrated into the practice’s electronic medical records system to screen for substance use at all well adolescent visits for adolescents aged 13-20 years. The Phase 1 training for providers focused on integration of SBIRT into a busy clinical session, management of positive screens, and referral resources. Phase 2 training reviewed Phase 1 performance, motivational interviewing, and trouble-shooting for the next cycle. Process measures included a pre- and post-Phase 1 provider survey (provider knowledge and comfort with screening/motivational interviewing) and chart review (socio-demographic data, substance use and sexual risk behaviors, service delivery). Data were analyzed using bivariate analyses using SPSS 24. Eighty charts were reviewed (40 pre-training, 40 post-Phase 1), and 9 providers were surveyed. Patients were predominantly white (71%), female (55%), Medicaid-insured (51.3%), with a mean age of 15.7 (STD 2.1). Pre-intervention, 12.5% of adolescents were identified as using substances, and 20% post-intervention. The most commonly used substance was marijuana (11.3%), followed by alcohol (6.3%), tobacco (2.5%), opioids (1.3%), and benzodiazepines (1.3%). From pre-intervention to post, the practice increased their frequency of screening with a validated tool (0% to 67.5%, p<0.001), providing any screening for substance use (85% to 97.5%, p=0.048), and providing a brief intervention (7.5% to 27.5%, p=0.019). From pre- to post-intervention, providers’ confidence improved (58.3% to 78.3%, p=0.005), and providers’ percent correct on the knowledge questions of the survey trended towards improvement (48.2% to 63.9%, p=0.082). Documentation regarding sexual health, a related, but non-targeted screening task, did not significantly improve (72.5% to 85%, p=0.17). Among the 31.5% of patients asked about sexual health, sexual activity was associated with substance use (45% versus 6.8%, p<0.001). Pediatric primary care providers trained in SBIRT and motivational interviewing can improve their screening and management of adolescent substance use. Expansion to pediatric practices in Maryland with a 3rd module focused on the relationship of substance use and sexual behavior is warranted.

Emerging Trends in Financing of Adult Heart Transplantation in the United States

ObjectivesThis study examined longitudinal trends in types of payers for adult heart transplantations in the United States. BackgroundIn the last decade, volume of heart transplantations in the United States has substantially increased, a trend that has coincided with Medicaid expansion and greater insurance coverage in the general U.S. population. Limited data are available characterizing the changes in payer mix supporting these recent increases in heart transplantation activity. MethodsDe-identified data were obtained from the Organ Procurement and Transplantation Network for heart transplantation recipients 18 to 64 years of age in the United States between 1997 and 2017. Primary sources of insurance payment were determined at the time of transplantation in aggregate and stratified by sex and race. Changes in volume and payer mix of patients added to the candidate waitlist between 1997 and 2017 were also examined. ResultsA total of 36,340 adults from 18 to 64 years of age underwent heart transplantations between 1997 and 2017. Support by public payer insurance increased from 28.2% (in 1997) to a peak of 48.8% (in 2016). Medicaid coverage increased from 9.4% in 1997 to 15.5% in 2007 and remained stable to 2017 (14.7%; β-coefficient: +0.23% [0.04]; p < 0.001 for trend). Medicare beneficiaries accounted for 18.2% of recipients in 1997, 22% in 2007, and 30.3% in 2016 (β-coefficient: +0.60% [0.06]; p < 0.001 for trend). The proportion of transplantation candidates receiving Medicare coverage increased over time across all races and both sexes. Similar aggregate patterns were observed in waitlist trends for adult heart transplantation candidates. ConclusionsPublic payer insurance has emerged as an increasingly dominant source of funding for adult heart transplantations in the United States, supporting nearly half of all transplants in 2017.

Impact of healthcare reform on the payer mix among young adult emergency department utilizers across the United States (2005-2015).

Before the patient protection and affordable care act (ACA), young adults (20 to 34) had the highest uninsured rates in the United States (US) and frequently sought care in emergency departments (EDs).We aimed to determine if there was a measurable effect of expanded coverage, specifically the dependent coverage provision and Medicaid expansion, on the payer mix of young adults in EDs.We performed a retrospective cross-sectional study of ED utilization among young adults across the US using the national hospital ambulatory medical care survey (NHAMCS) (2005–2015).We examined the effect of health reform changes on the prevalence and odds of having an insurance type among ED utilizers (19–30) in 3 time periods (2005–2010), (2011–2013), and (2014–2015). Additionally, we compared the national and ED payer mix proportions among 19 to 25 and 26 to 30-year-olds.Our results indicate significant proportional changes in the national and ED payer mix relative to a pre-ACA time period. The 2 greatest changes to the national payer mix were the reduction in the proportion of uninsured/self-payers and the increase in the proportion covered by Medicaid. Furthermore, the dependent coverage provision was effective in increasing the proportion of those (19–25) utilizing private insurance coverage. Lastly, there is now a lower proportion of uninsured young adults in the ED, and an increased proportion of those covered by Medicaid.The change in payer mix among young adults has potential long-term consequences for the provision of emergency department services in the U.S.

Pediatric Inpatient-Status Volume and Cost at Children's and Nonchildren's Hospitals in the United States: 2000-2009.

The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs. A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database. Weighted discharge data were used to generate national estimates for a comparison of inpatient volume, cost, and complexity at CHs and nonchildren's hospitals (NCHs). Linear regression was used to assess how complexity, payer mix, and hospital-level characteristics affected inflation-adjusted costs. Between 2000 and 2009, the number of discharges per 1000 children increased from 6.3 to 7.7 at CHs and dropped from 55.4 to 53.3 at NCHs. The proportion of discharges at CHs grew by 6.8% between 2006 and 2009 alone. In 2009, CHs were responsible for 12.6% (95% confidence interval: 10.4%-14.9%) of pediatric discharges and 14.7% of major therapeutic procedures, yet they accounted for 23.0% of inpatient costs. Costs per discharge were significantly higher at CHs than at NCHs for all years (P < .001); however, the increase in costs seen over time was not significant. Care complexity increased during the study period at both CHs and NCH, but it could not be used to fully account for the difference in costs. National trends reveal a small rise in both the proportion of inpatient discharges and the hospital costs at CHs, with costs being significantly higher at CHs than at NCHs. Research into factors influencing costs and the role of CHs is needed to inform policy and contain costs.

The Evolving Practice Patterns of Academic Endocrine Surgeons: A Cross-sectional Analysis of the Faculty Practice Solutions Center Database 2014 to 2017.

To examine the evolution of an academic endocrine surgeon's practice over time. Amid growing recognition that surgical volume and specialization are linked to better outcomes, endocrine surgery is one of the youngest fields to develop its own formal fellowship training program. However, 3 decades after the emergence of endocrine surgery as a distinct specialty, the medical community and public still have a limited understanding of endocrine surgeons and what they do. We performed a cross-sectional analysis of endocrine surgeons identified in the Faculty Practice Solutions Center Database from 2014 to 2017. Trends in annual number of endocrine surgeries performed, number of all surgeries performed, total work relative value units generated, and patient payer mix stratified by years of practice were evaluated. One hundred thirty-nine endocrine surgeons practicing in 103 institutions over 4 years were analyzed. The proportion of endocrine-specific operations increases over time. A typical academic endocrine surgeon meets the high-volume threshold for thyroidectomies early in their career, but does not reach the thresholds for parathyroidectomies or adrenalectomies until after 4 years. Increased productivity as reflected by adjusted work relative value units does increase over the first 15 years of practice, but also decreases as the proportion of endocrine-specific practice increases. The greatest proportion of endocrine surgeons' patients are insured by commercial plans (46%-50%), and payer mix is stable across all levels of practice. Although endocrine surgeons perform a high-volume of endocrine-specific operations, practice patterns are heterogeneous and suggest that most surgeons have to grow their endocrine-specific practice over time.

Variation in Triple Aim Measures: Implications of Clinical Signatures in Family Medicine Residency Programs

Evidence from several specialties suggests that practice patterns developed in residency influence the quality and cost of care long after completion of training. Improving the quality, cost, and patient experience of care (the "Triple Aim") is foundational to future health systems change. We measured variation in Triple Aim measures among family medicine residency programs in a regional quality improvement collaborative (I3 Population Health Collaborative). We calculated medians and interquartile ranges for each of 11 Triple Aim measures and compared them with median splits of population and practice characteristics, including payer mix, patient race and age, electronic health record used, registry use, and National Committee for Quality Assurance patient-centered medical home recognition. All 22 participating family medicine residency programs provided baseline data. The number of practices reporting data on individual measures ranged from 9 to 17 (41%-77%). We found variation averaging 51% across all measures, from a low of 12% for readmission rates to 94% for emergency department visit rates. Variations were stable over time. We found no significant relationships between practice or population characteristics and measures, nor between practice characteristics and outcomes variation. The 22 family medicine residency programs in our study showed substantial variation in quality, cost, and patient experience of care. These variations did not appear to result from differences in practice characteristics, payer mix, or patient demographics.

Closing the Equity Gap of Access to Emergency Departments of Private Hospitals in Thailand.

Background Previous policy implementation in 2012 to incentivize private hospitals in Thailand, a country with universal health coverage, to provide free-of-charge emergency care using DRG-based payment resulted in an equity gap of access and copayment. To bridge the gap, strategic policies involving financial and legal interventions were implemented in 2017. This study aims to assess whether this new approach would be able to fill the gap. Methods We analyzed an administrative dataset of over 20,206 patients visiting private hospital EDs from April 2017 to October 2017 requested for the preauthorization of access to emergency care in the first 72 hours free of charge. The association between types of insurance and the approval status was explored using logistic regression equation adjusting for age, modes of access, systolic blood pressure, respiratory rate, and Glasgow coma scores. Results and Discussion The strategic policies implementation resulted in reversing ED payer mix from the most privileged scheme, having the major share of ED visit, to the least privileged scheme. The data showed an increasing trend of ED visits to private hospitals indicates the acceptance of the financial incentive. Obvious differences in degrees of urgency between authorized and unauthorized patients suggested the role of preauthorization as a barrier to the noncritical patient visiting the ED. Furthermore, our study depicted the gender disparity between authorized and unauthorized patients which might indicate a delay in care seeking among critical female patients. Lessons learned for policymakers in low-and-middle income countries attempting to close the equity gap of access to private hospital EDs are discussed.

Variation in Medication Therapy Management Delivery: Implications for Health Care Policy.

Medication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources. To apply the CCM to understand variation in MTM delivery and formulate policy recommendations. This study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements. Seven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice's core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified. Our research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation. This research and a portion of Snyder's salary were supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Snyder reports consulting fees from Westat for an evaluation of the CMS Enhanced MTM program. The other authors have nothing to disclose. Portions of this research have been presented as abstracts at the following conferences: (a) 2017 Academy Health Annual Research Meeting; June 25-27, 2017; New Orleans, LA; (b) 2015 American Society of Health-System Pharmacists Clinical Midyear Meeting; December 4-8, 2015; New Orleans, LA; and

The impact of an acute care surgery model on general surgery service productivity

BackgroundThe Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. MethodsUsing WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013–September, 2015) and two years after (October, 2015–September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. ResultsThere was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post-ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08). There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). ConclusionsShifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service.

A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery.

ObjectiveWe investigate the cost-effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice. MethodsThe time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue. ResultsA total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases. ConclusionApplication of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery.

Association of State Medicaid Expansion With Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014.

Cardiovascular disease is the leading primary diagnosis among all hospital discharges, and insurance status is associated with patient outcomes. The association of state-level policy decisions regarding the Affordable Care Act (ACA) Medicaid expansion with rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality has not been investigated to date. To investigate whether the rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality varied by state-level policy on ACA Medicaid expansion. For this cohort study, difference-in-differences analysis of data from the Healthcare Cost and Utilization Project State Inpatient Databases of 30 US states on 524 848 non-Medicare hospitalizations in 2014 and a mean of 516 811 non-Medicare hospitalizations per year from 2009 to 2013 was performed for major cardiovascular events (defined as a composite of acute myocardial infarction, stroke, and heart failure) from January 1, 2009, through December 31, 2014. Analyses were completed September 1, 2017. State Medicaid expansion as of January 1, 2014. Comparison of mean payer mix proportions (uninsured, Medicaid, and privately insured) and in-hospital mortality between expansion and nonexpansion states for the years preceding the ACA Medicaid expansion (2009-2013) and the year after the ACA Medicaid expansion (2014). Of the 801 819 hospitalizations in the 17 expansion states in 2014, 428 503 (53.4%) patients were men, 514 036 (64.1%) were white, and 365 797 (45.6%) were aged 65 to 84 years. Of 719 459 hospitalizations in the 13 nonexpansion states in 2014, 383 311 (53.3%) patients were men, 492 136 (68.4%) were white, and 335 781 (46.7%) were aged 65 to 84 years. There were 281 184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243 664 non-Medicare hospitalizations in the 13 nonexpansion states in 2014. In multivariable regression analyses, the expansion states had a significant 5.8-percentage point decrease in the proportion of uninsured hospitalizations after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, -0.058; 95% CI, -0.075 to -0.042; P < .001). The expansion states also had a significant 8.4-percentage point increase in the Medicaid share after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065 to 0.102; P < .001). In-hospital mortality did not change significantly after Medicaid expansion in either the expansion states (before ACA, 3.8% vs after ACA, 3.7%) or the nonexpansion states (4.0% vs 4.0%). States that expanded Medicaid during the ACA implementation had a significantly greater reduction in the proportion of uninsured hospitalizations for major cardiovascular events compared with the nonexpansion states. This study suggests that expansion status was not associated with in-hospital mortality rates in the first year after ACA implementation.

Physicians' Participation In Medicaid Increased Only Slightly Following Expansion.

While most primary care physicians treated at least one Medicaid patient in 2013, Medicaid represented a small share of their payer mix. Following Medicaid eligibility expansion in 2014, most physicians maintained or slightly increased their Medicaid participation, with greater increases observed in states that expanded eligibility. Nevertheless, Medicaid patients remained concentrated among relatively few physicians after expansion.

The Impact of Implementation of a Clinically Integrated Problem-Based Neonatal Electronic Health Record on Documentation Metrics, Provider Satisfaction, and Hospital Reimbursement: A Quality Improvement Project.

BackgroundA goal of effective electronic health record provider documentation platforms is to provide an efficient, concise, and comprehensive notation system that will effectively reflect the clinical course, including the diagnoses, treatments, and interventions.ObjectiveThe aim is to fully redesign and standardize the provider documentation process, seeking improvement in documentation based on ongoing All Patient Refined Diagnosis Related Group–based coding records, while maintaining noninferiority comparing provider satisfaction to our existing documentation process. We estimated the fiscal impact of improved documentation based on changes in expected hospital payments.MethodsEmploying a multidisciplinary collaborative approach, we created an integrated clinical platform that captures data entry from the obstetrical suite, delivery room, neonatal intensive care unit (NICU) nursing and respiratory therapy staff. It provided the sole source for hospital provider documentation in the form of a history and physical exam, daily progress notes, and discharge summary. Health maintenance information, follow-up appointments, and running contemporaneous updated hospital course information have selected shared entry and common viewing by the NICU team. The interventions were to (1) improve provider awareness of appropriate documentation through a provider education handout and follow-up group discussion and (2) fully redesign and standardize the provider documentation process building from the native Epic-based software. The measures were (1) hospital coding department review of all NICU admissions and 3M All Patient Refined Diagnosis Related Group–based calculations of severity of illness, risk of mortality, and case mix index scores; (2) balancing measure: provider time utilization case study and survey; and (3) average expected hospital payment based on acuity-based clinical logic algorithm and payer mix.ResultsWe compared preintervention (October 2015-October 2016) to postintervention (November 2016-May 2017) time periods and saw: (1) significant improvement in All Patient Refined Diagnosis Related Group–derived severity of illness, risk of mortality, and case mix index (monthly average severity of illness scores increased by 11.1%, P=.008; monthly average risk of mortality scores increased by 13.5%, P=.007; and monthly average case mix index scores increased by 7.7%, P=.009); (2) time study showed increased time to complete history and physical and progress notes and decreased time to complete discharge summary (history and physical exam: time allocation increased by 47%, P=.05; progress note: time allocation increased by 91%, P<.001; discharge summary: time allocation decreased by 41%, P=.03); (3) survey of all providers: overall there was positive provider perception of the new documentation process based on a survey of the provider group; (4) significantly increased hospital average expected payments: comparing the preintervention and postintervention study periods, there was a US $14,020 per month per patient increase in average expected payment for hospital charges (P<.001). There was no difference in payer mix during this time period.ConclusionsA problem-based NICU documentation electronic health record more effectively improves documentation without dissatisfaction by the participating providers and improves hospital estimations of All Patient Refined Diagnosis Related Group–based revenue.

Hospital Variation in Intensive Care Resource Utilization and Mortality in Newly Diagnosed Pediatric Leukemia.

To evaluate hospital-level variability in resource utilization and mortality in children with new leukemia who require ICU support, and identify factors associated with variation. Retrospective cohort study. Children's hospitals contributing to the Pediatric Health Information Systems administrative database from 1999 to 2011. Inpatients less than 25 years old with newly diagnosed acute lymphocytic leukemia or acute myeloid leukemia requiring ICU support (n = 1,754). Evaluated exposures included leukemia type, year of diagnosis, and hospital-wide proportion of patients with public insurance. The main outcome was hospital mortality. Wide variability existed in the ICU resources used across hospitals. Combined acute lymphocytic leukemia and acute myeloid leukemia mortality varied by hospital from 0% (95% CI, 0-14.8%) to 42.9% (95% CI, 17.7-71.1%). A mixed-effects model with a hospital-level random effect suggests significant variation across hospitals in mortality (p = 0.007). When including patient and hospital factors as fixed effects into the model, younger age, acute myeloid leukemia versus acute lymphocytic leukemia diagnosis, leukemia diagnosis prior to 2005, hospital-wide proportion of public insurance patients, and hospital-level proportion of leukemia patients receiving ICU care are significantly associated with mortality. The variation across hospitals remains significant with all patient factors included (p = 0.021) but is no longer significant after adjusting for the hospital-level factors proportion of public insurance and proportion receiving ICU care (p = 0.48). Wide hospital-level variability in ICU resource utilization and mortality exists in the care of children with leukemia requiring ICU support. Hospital payer mix is associated with some mortality variability. Additional study into how ICU support could be standardized through clinical practice guidelines, impact of payer mix on hospital resources allocation to the ICU, and subsequent impact on patient outcomes is warranted.

Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession.

There has been ongoing concern regarding the viability of safety-net hospitals (SNHs), which care for vulnerable populations. The authors examined payer mix at SNHs and non-SNHs during a period covering the Great Recession using data from the 2006 to 2012 Healthcare Cost and Utilization Project State Inpatient Databases from 38 states. The number of privately insured stays decreased at both SNHs and non-SNHs. Non-SNHs increasingly served Medicaid-enrolled and uninsured patients; in SNHs, the number of Medicaid stays decreased and uninsured stays remained stable. These study findings suggest that SNHs were losing Medicaid-enrolled patients relative to non-SNHs before the Medicaid expansion under the Affordable Care Act (ACA). Postexpansion, Medicaid stays will likely increase for both SNHs and non-SNHs, but the increase at SNHs may not be as large as expected if competition increases. Because hospital stays with private insurance and Medicaid help SNHs offset uncompensated care, a lower-than-expected increase could affect SNHs' ability to care for the remaining uninsured population. Continued monitoring is needed once post-ACA data become available.

Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals

Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability. We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin. California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n= 4) and nonprofit-owned SNHs (64%, n= 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p<0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively. The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.

Abstract 22: Association of Hospital Race and Payer Mix With Inpatient Mortality Among Patients Admitted for Acute Coronary Syndrome, Heart Failure and Arrhythmia

Background: Patient characteristics insufficiently explain observed disparities in cardiovascular outcomes among hospitalized patients, suggesting a role for community or hospital-level factors. Here, we evaluate the association of hospital segregation by black race and payer mix with inpatient mortality using a nationally representative sample of hospitalizations. Methods: Using the National Inpatient Sample (NIS), we identified adult hospitalizations with a primary diagnosis of acute coronary syndrome (n=550,005), heart failure (n=863,870) and atrial/ventricular arrhythmia (n=656,070). We divided NIS hospitals in to quartiles based on percent of hospital black and low payer (Medicaid or uninsured) admissions. We utilized logistic regression to determine whether hospital race or low payer quartile was associated with inpatient mortality among those admitted for acute coronary syndrome (ACS), heart failure (HF) and atrial/ventricular arrhythmia. Models were adjusted for age, sex, patient comorbidities, and hospital characteristics. Results: The mean age (95% CI) of the ACS, HF, and arrhythmia cohorts was 66.8 (66.7-67.0), 71.7 (71.5-71.9) and 70.0 (69.8-70.1) years, respectively. In adjusted models, ACS patients admitted to hospitals with &gt;18.7-25.7% (Q2), &gt;25.7%-34.0% (Q3), and &gt;34.0% (Q4) low payer admissions experienced a 12% (OR 1.12, 1.03-1.20), 10% (OR 1.10, 1.01-1.19), and 12% (OR 1.12, 1.02-1.23) increased odds of inpatient mortality, respectively, when compared to hospitals with ≤18.7% low payer admissions (Q1). In the arrhythmia cohort, patients admitted to hospitals with &gt;34.0% (Q4) low payer admissions experienced a 25% increased odds of inpatient mortality compared to those admitted to hospitals with ≤18.7% (Q1) low payer admissions (OR 1.25, 1.11-1.41). Among heart failure patients, those admitted to hospitals with &gt;20.5% (Q4) black patients experienced a 17% (OR 0.83, 0.74-0.93) decreased odds of inpatient mortality compared to those admitted to hospitals with ≤4% (Q1) black admissions. Conclusion: Hospital low payer makeup positively associates with odds of inpatient mortality among patients admitted for acute coronary syndrome and arrhythmia. Hospital black makeup inversely associates with odds of inpatient mortality among patients admitted for heart failure.