Costs of health care administration in the United States and Canada

Characterizing the burden of biliary tract cancers across 28 hospitals in Ontario, Canada

BACKGROUND AND AIMS

The incidence of biliary tract cancers (BTC) appears to be increasing worldwide. We analyzed the characteristics of BTC-related hospitalizations under medical services across 28 hospitals in Ontario, Canada.

METHODS

This study uses data collected by GEMINI, a hospital research data network. BTC-related hospitalizations from 2015 to 2021 under the Department of Medicine or intensive care unit were captured using the International Classification of Diseases, 10th revision, codes for intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma, and gallbladder cancers.

RESULTS

A total of 4596 BTC-related hospitalizations (2720 iCCA, 1269 extrahepatic cholangiocarcinoma, 607 gallbladder cancers) were analyzed. The number of unique patients with BTC-related hospitalizations increased over time. For iCCA-related hospitalizations, the total number of hospitalizations increased (from 385 in 2016 to 420 in 2021, p = .005), the hospital length of stay decreased over the study period (mean 10 days [SD, 12] in 2016 to 9 days [SD, 8] in 2021, p = .04), and the number of in-hospital deaths was stable (from 68 [18%] in 2016 to 55 [13%] in 2021, p = .62). Other outcomes such as 30-day readmissions, medical imaging tests, intensive care unit-specific hospitalizations, and length of stay were stable over time for all cohorts. The cost of hospitalization for the BTC cohort increased from median $8203 CAD (interquartile range, 5063-15,543) in 2017 to $8507 CAD (interquartile range, 5345-14,755) in 2021.

CONCLUSIONS

This real-world data analysis showed a rising number of patients with BTC-related hospitalizations and rising number of iCCA-related hospitalizations across 28 hospitals in Ontario between 2015 and 2021.

ChatGPT-4 generates orthopedic discharge documents faster than humans maintaining comparable quality: a pilot study of 6 cases

BACKGROUND AND PURPOSE

Large language models like ChatGPT-4 have emerged. They hold the potential to reduce the administrative burden by generating everyday clinical documents, thus allowing the physician to spend more time with the patient. We aimed to assess both the quality and efficiency of discharge documents generated by ChatGPT-4 in comparison with those produced by physicians.

PATIENTS AND METHODS

To emulate real-world situations, the health records of 6 fictional orthopedic cases were created. Discharge documents for each case were generated by a junior attending orthopedic surgeon and an advanced orthopedic resident. ChatGPT-4 was then prompted to generate the discharge documents using the same health record information. The quality assessment was performed by an expert panel (n = 15) blinded to the source of the documents. As secondary outcome, the time required to generate the documents was compared, logging the duration of the creation of the discharge documents by the physician and by ChatGPT-4.

RESULTS

Overall, both ChatGPT-4 and physician-generated notes were comparable in quality. Notably, ChatGPT-4 generated discharge documents 10 times faster than the traditional method. 4 events of hallucinations were found in the ChatGPT-4-generated content, compared with 6 events in the human/physician produced notes.

CONCLUSION

ChatGPT-4 creates orthopedic discharge notes faster than physicians, with comparable quality. This shows it has great potential for making these documents more efficient in orthopedic care. ChatGPT-4 has the potential to significantly reduce the administrative burden on healthcare professionals.

Administration's Share of Personnel in Veterans Health Administration and Private Sector Care

Importance

Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA).

Objective

To compare administrative staffing patterns in the VHA and private (non-VHA) sectors.

Design, Setting, and Participants

This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed.

Exposure

VHA vs private sector health care employment, including 397 occupations grouped into 18 categories.

Main Outcome and Measure

The proportion of staff working in administrative occupations.

Results

Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector.

Conclusions and Relevance

In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.

National Analysis of Health care Related Costs for Health care Workers and Administrators Over the Past Decade: Toward Establishing Sustainable and Cost Effective Health care System

BACKGROUND

We aim to investigate the costs associated with growth in the administrators, health care staff, and physicians to provide direction to establish a sustainable and cost-effective U.S. health care system.

METHODS

Data from the U.S. Bureau of Labor Statistics, particularly the Labor Force Statistics from the Current Population Survey, were utilized from 2009 to 2020. Wages and employment of medical and health service managers (administrators), health care practitioners and technical operations (health care staff), and physicians were used to calculate the total cost.

RESULTS

Administrator wages have grown similarly to health care staff wages (-4.40 vs -3.01%, P = .454) and physician wages (-4.40 vs -3.29%, P = .672). Additionally, there has been a similar increase in health care staff employment (9.91 vs 14.23%, P = .269) and physician employment (9.91 vs 15.35%, P = .252) compared to administrator employment. Overall, the total growth in administrator cost is similar to the growth in total health care staff cost (6.23 vs 11.80, P = .104) and total physician cost (6.23 vs 13.02%, P = .079). In 2020, physicians had the highest employment growth but the smallest wage increase.

CONCLUSION

Although health care staff experienced a greater percent growth in employment and cost per employee than administrators since 2009, the cost per administrator remains greater than that of health care staff. Understanding differences in wages and costs is essential to reduce health care spending without compromising access, delivery, and quality of health care services.

Private Equity: The Bad and the Ugly

Private equity's (PE) presence has grown within dermatology over the last decade, creating a new landscape for dermatologists to navigate. Although dermatology PE-backed groups (DPEGs) claim to partner with physicians and improve health care delivery, their actions show that investment returns and profits are prioritized. The history of PE in medicine, the corporate practice of medicine, maturation of the dermatology market, monopolistic practices, overleveraging of nonphysician practitioners, dependence on debt, training under PE, and professional and lifestyle considerations are discussed. Dermatologists should be wary of DPEGs in order to protect the profession and patients.

Value-Based Care and Anesthesiology in the USA

Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this patient-centric approach, anesthesiologists are adopting dynamic roles to meet the demands of medical institutions, insurers, and patients for high-quality, cost-effective care. The urgency for this transition is accentuated by persistent challenges in reducing postoperative mortality rates and surgical complications, further spotlighted by the coronvirus disease 2019 (COVID-19) pandemic. Anesthesiologists engage in preoperative optimization, personalized care delivery, and evidence-based practices, bolstering their influence in the perioperative environment. Their collaboration with perioperative stakeholders propels the shift toward a value-driven healthcare landscape. This review analyzes the implementation of value-based care in American anesthesiology, assesses the significance of technology in enhancing its delivery, and outlines potential strategies for improving its application.

Doing primary care integration: a qualitative study of meso-level collaborative practices

BACKGROUND

The integration of Primary Care (PC) into broader health systems has been a goal in jurisdictions around the world. Efforts to achieve integration at the meso-level have drawn particular attention, but there are few actionable recommendations for how to enact a 'pro-integration culture' amongst government and PC governance bodies. This paper describes pragmatic integration activity undertaken by meso-level participants in Alberta, Canada, and suggests ways this activity may be generalizable to other health systems.

METHODS

11 semi-structured interviews with nine key informants from meso-level organizations were selected from a larger qualitative study examining healthcare policy development and implementation during the COVID-19 pandemic. Selected interviews focused on participants' experiences and efforts to 'do' integration as they responded to Alberta's first wave of the Omicron variant in September 2021. An interpretive descriptive approach was used to identify repeating cycles in the integration context, and pragmatic integration activities.

RESULTS

As Omicron arrived in Alberta, integration and relations between meso-level PC and central health system participants were tense, but efforts to improve the situation were successfully made. In this context of cycling relationships, staffing changes made in reaction to exogenous shocks and political pressures were clear influences on integration. However, participants also engaged in specific behaviours that advanced a pro-integration culture. They did so by: signaling value through staffing and resource choices; speaking and enacting personal and group commitments to collaboration; persevering; and practicing bi-directional communication through formal and informal channels.

CONCLUSIONS

Achieving PC integration involves not just the reactive work of responding to exogenous factors, but also the proactive work of enacting cultural, relationship, and communication behaviors. These behaviors may support integration regardless of the shocks, staff turnover, and relational freeze-thaw cycles experienced by any health system.

Futureproofing Social Support Policies for Population Health

Policy Points In America, wages appear to be growing relative to purchasing power over time. However, while the ability to purchase consumer goods has indeed improved, the cost of basic survival needs such as health care and education has increased faster than wages have grown. America's weakening social policy landscape has led to a massive socioeconomic rupture in which the middle class is disappearing, such that most Americans now cannot afford basic survival needs, such as education and health insurance. Social policies strive to rebalance societal resources from socioeconomically advantaged groups to those in need. Education and health insurance benefits have been experimentally proven to also improve health and longevity. The biological pathways through which they work are also understood.

Falling ill raises the health insurer's administration bill

In many countries, governments use payment systems to compensate health insurers more for enrollees with higher expected costs. However, little empirical research has examined whether these payment systems should also include health insurers' administrative costs. We provide two sources of evidence that health insurers with a more morbid population have higher administrative costs. First, we show at the customer level a causal relationship between individual morbidity and individual administrative contacts with the insurer, using the weekly evolution of the number of individual customer contacts (calls, emails, in-person visits etc.) of a large Swiss health insurer. Using a difference-in-differences design, we find that the onset of a chronic illness causes on average a persistent increase of about 40% in individuals' contacts with the health insurer. Second, we provide evidence that this relationship also holds for total administrative costs at the insurer level. We study twenty years of Swiss health insurance market data and find a positive elasticity of around 1, indicating that, all else equal, an insurer with a more morbid population, equal to 1% more health care spending, faces about 1% higher administrative costs.

The Use of Chatbots in Oncological Care: A Narrative Review

Background

Few reports have investigated chatbots in patient care. We aimed to assess the current applications, limitations, and challenges in the literature on chatbots employed in oncological care.

Methods

We queried the PubMed database through April 2022 and included studies that investigated the use of chatbots in different phases of oncological care. The search used five different combinations of the specific terms "chatbot", "cancer", "oncology", and "conversational agent". Inclusion criteria were chatbot use in any aspect of oncological care-prevention, patient education, treatment, and surveillance.

Results

The initial search yielded 196 records, 21 of which met inclusion criteria. The identified chatbots mostly focused on breast and ovarian cancer (n=8), with the second most common being cervical cancer (n=3). Good patient satisfaction was reported among 14 of 21 chatbots. The most reported chatbot applications were cancer screening, prevention, risk stratification, treatment, monitoring, and management. Of 12 studies examining efficacy of care via chatbot, 9 demonstrated improvements compared to standard care.

Conclusion

Chatbots used for oncological care to date demonstrate high user satisfaction, and many have shown efficacy in improving patient-centered communication, accessibility to cancer-related information, and access to care. Currently, chatbots are primarily limited by the need for extensive user-testing and iterative improvement before widespread implementation.

The No Surprises Act: A Conservative Band-Aid to Protect Business as Usual

Hailed as a major reform, the No Surprises Act (NSA) is a profoundly conservative law that aims neither to reform design of insurance, to regulate fees, nor to limit health care spending. The NSA mitigates a perverse but narrow problem: unpredictable and uncontrollable high out-of-pocket bills for individuals who are unable to receive care within their insurance network. However, the NSA neglects to address the broader high medical costs, limited choice of caregivers, and the resulting insecurity and unfairness that characterize American health care. It allows caregivers to extract high payments and insurers to restrict choice of caregivers. Insurers can continue to employ ineffective cost controls that generate unpredictable high out-of-pocket costs for patients-and high levels of denial of payments to doctors and hospitals. The law amputated the most politically and visibly gangrenous consequences of unregulated private insurance in the United States in ways that enable business as usual in private health insurance to persist, subject to unnecessarily complex arbitration rules that magnify administrative waste.

Billing And Insurance-Related Administrative Costs: A Cross-National Analysis

Billing and insurance-related costs are a significant source of wasteful health care spending in Organization for Economic Cooperation and Development nations, but these administrative burdens vary across national systems. We executed a microlevel accounting of these costs in different national settings at six provider locations in five nations (Australia, Canada, Germany, the Netherlands, and Singapore) that supplements our prior study measuring the costs in the US. We found that billing and insurance-related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted). We created a taxonomy of billing and insurance-related activities (eligibility, coding, submission, and rework) that was applied to data from the six sites and allows cross-national comparisons. Higher costs in the US and Australia are attributed to high coding costs. Much of the savings achieved in some nations is attributable to assigning tasks to people in lower-skill job categories, although most of the savings are due to more efficient billing and insurance-related processes. Some nations also reduce these costs by offering financial counseling to patients before treatment. Our microlevel approach can identify specific cost drivers and reveal national billing features that reduce coding costs. It illustrates a valuable pathway for future research in understanding and mitigating administrative costs in health care.

The American Public Health Association Endorses Single-Payer Health System Reform

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.

Facial Feminization Surgery under Insurance: The University of California Los Angeles Experience

Despite improved insurance coverage for gender confirmation surgeries in the United States, coverage for facial feminization surgery (FFS) continues to be difficult. Here, we describe our institutional experience on navigation, time, and costs of the FFS insurance authorization process.

The Impact of Global Budgeting on the Efficiency of Healthcare under a Single-Payer System in Taiwan

Since 1995, a national health insurance (NHI) program has been in operation in Taiwan, which provides uniform comprehensive coverage. Forced by severe financial deficit, global budgeting reimbursement was adopted in the healthcare sector to control healthcare expenditures in 2002. A two-stage data envelopment analysis (DEA) approach was used to measure the efficiency of hospital resource allocation among stakeholders in Taiwan’s NHI system, and to further explore the changes in resource allocation after the introduction of a global budgeting payment scheme. The dataset was collected from the annual statistical reports of Taiwan’s Ministry of Health and Welfare (MOHW) and was used to estimate the efficiency of resource allocation in hospital-based healthcare services under global budgeting. In terms of efficiency during the period from 2003 to 2009, one-third of decision-making units (DMUs) improved their productivity in stage I, and seven out of the total of eighteen DMUs saw falls in financial efficiency in stage II. After global budgeting was implemented, there were significant positive impacts on the efficiency of hospital resource allocation in Taiwan. The two-stage DEA model for analyzing the effects of the global budgeting reimbursement system on productivity and financial efficiency represents a key decision-making tool for hospital administrators and policymakers.

Hospitalizations and Outcomes of T1MI Observed Before and After the Introduction of MI Subtype Codes

BACKGROUND

International Classification of Disease (ICD)-10 coding of type 1 myocardial infarction (MI) is used for reimbursement, value-based programs, and clinical research.

OBJECTIVES

This study sought to determine whether the introduction of ICD-10 codes for type 2 and types 3-5 MI was associated with changes in hospitalizations for ICD-10 codes now attributed to type 1 MI.

METHODS

Using the Nationwide Readmissions Database, we identified patients with ICD-10 codes now attributed to type 1 MI between January 2016 and December 2018. Patients were stratified according to the timing of their event in relation to the introduction of the type 2 and types 3-5 MI codes on October 1, 2017.

RESULTS

There were 2,680,323 hospitalizations for ICD-10 codes now attributed to type 1 MI; after adjustment for seasonality, there was a 13.7% decline in hospitalizations after the introduction of the new subtype codes. Patients with ICD-10 codes now attributed to type 1 MI after the coding change were less likely to be female, had lower prevalence of several cardiovascular and noncardiovascular comorbidities, and had higher rates of coronary angiography and revascularization. After introduction of the new codes, there was a positive deflection in the slope of risk-adjusted in-hospital mortality (0.007%; P <0.001) and a negative deflection in risk-adjusted 30-day readmission (-0.002%; P = 0.05) for patients with ICD-10 codes now attributed to type 1 MI.

CONCLUSIONS

The introduction of ICD-10 codes for type 2 and types 3-5 MI was associated with a decrease in hospitalizations for ICD-10 codes now attributed to type 1 MI and changes in the observed characteristics and treatment patterns of these patients.

Insurance reimbursements for recombinant zoster vaccine in the private sector

A two-dose series of the recombinant zoster vaccine (RZV, Shingrix) was licensed by the Food and Drug Administration in 2017 and recommended by the Advisory Committee on Immunization Practices in 2018 for adults in the United States age 50 years and older. Despite the health benefits of shingles vaccination, coverage has remained low, with financial barriers among healthcare providers identified as one potential factor. This study estimates the reimbursement levels for RZV among a large sample of privately insured individuals in the US from the 2018 IBM® MarketScan® Commercial Claims and Encounters database. Of 198,534 claims for an RZV dose, the mean reimbursement was $149. Most claims (83%) exceeded $140, which was the private sector vaccine price reported on the CDC vaccine price list in April 2018. These results can be useful for providers considering procuring RZV and for state immunization programs considering ways to improve vaccination coverage.

Reducing administrative costs in US health care: Assessing single payer and its alternatives

OBJECTIVE

Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them.

DATA SOURCES

Literature review and national utilization and expenditure data.

STUDY DESIGN

We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing.

DATA EXTRACTION

For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters.

PRINCIPAL FINDINGS

Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies.

CONCLUSION

Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.

Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon

OBJECTIVES

To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population.

METHODS

Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r).

RESULTS

Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001.

CONCLUSIONS

Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

Risk Factors of Metabolic Syndrome among Polish Nurses

The metabolic syndrome, also known as syndrome X or the insulin resistance, is defined by the World Health Organization as a pathologic condition characterized by abdominal obesity, insulin resistance, hypertension, and hyperlipidemia. Both all over the world and in Poland, there is a shortage of nurses; most of those employed are in the pre-retirement age. However, the requirements in this profession and the patient’s right to care at the highest level remain unchanged and do not take into account the poor condition or age of working nurses, so special attention should be paid to the state of health in this professional group. There is an emphasis on the importance of the adopted attitude toward health and the resulting behaviors, such as regular weight control, following dietary recommendations, regular physical activity and participation in preventive examinations. The aim of the study was to assess the frequency of the occurrence of the metabolic syndrome, its individual components and determining the factors influencing its development in Polish nurses. The research conducted among the nurses in question included DXA (Dual Energy X-ray Absorptiometry) measurements, assessment of glucose concentration, lipid profile, blood pressure and a questionnaire survey. Almost half of the surveyed nurses have metabolic syndrome, which significantly increases the risk of developing cardiovascular diseases or diabetes. After multivariate analysis, it was found that being overweight and obesity were significant factors influenced the MS (metabolic syndrome) occurrence among Polish nurses. Being overweight increases the chances of MS occurrence 8.58 times in relation to BMI (Body Mass Index) <25, obesity increases the chances of MS occurrence 8.085 times in relation to BMI <25, and obesity class II/III increases the chances of MS occurrence 16.505 times in relation to BMI <25. Preventive and supportive measures for this professional group are needed.

An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants

To assess national expenditure associated with preterm-infant brain MRI and potential impact of reduction per Choosing Wisely campaign 2015 recommendation to “avoid routine screening term-equivalent or discharge brain MRIs in preterm-infants”. Cross-sectional U.S. trend data from the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) database (2006, 2009, 2012, 2016) was used to estimate overall national expenditure associated with brain MRI among infants with gestational age (GA) ≤36 weeks, and also when classified as ‘not indicated’ (NI-MRI) i.e., equivalent to routine use without clinical indications and regarded as low-value service (LVS). Associated cost was determined by querying CMS-database for physician-fee-schedules to find the highest global procedure-cost per cycle, then adjusting for inflation. Sensitivity-analyses were conducted to account for additional clinical charges associated with NI-MRI. 3,768 (0.26%) of 1,472,236 preterm-infants had brain MRI across all cycles (inflation-adjusted total $3,690,088). Overall proportion of brain MRIs increased across 2006–2012 from 0.25%-0.33% but decreased in 2016 to 0.16% (P<0.001). Inflation-adjusted overall expenditure by cycle was: 2006, $1,299,130 (95% CI: $987,505, $1,610,755); 2009, $1,194,208 (95% CI: $873,487, $1,516,154); 2012, $931,836 (95% CI: $666,114, $1,197,156); and 2016, $264,648 (95% CI: $172,061, $357,280). Prevalence for NI-MRI in 2006, 2009, 2012 and 2016 was 86% (n = 809), 88% (n = 940), 89% (n = 1028) and 50% (n = 299), respectively; and 70% were in infants 35–36 weeks GA. NI-MRI prevalence was not different over time by payer-type (Medicaid, private), sex or race/ethnicity (white, black, Hispanic); larger hospital size was significantly associated across 2006–2012 but this declined for all sizes in 2016, with most decline in larger hospitals (P for interaction <0.05). NI-MRI expenditure sensitivity-analysis with addition of cycle median total-admission-charge to inflation-adjusted CMS-fee was $1,190,919/$518,343, for 2012/2016 cycles respectively. National MRI prevalence in preterm infants (both overall and LVS) and associated expenditure decreased substantially post recommendation; however, annual savings are modest and unlikely to be >$1.2 million.

Vertebroplasty and kyphoplasty in the USA from 2004 to 2017: national inpatient trends, regional variations, associated diagnoses, and outcomes

BACKGROUND

To explore the national inpatient trends, regional variations, associated diagnoses, and outcomes of vertebral augmentation (vertebroplasty and kyphoplasty) in the USA from 2004 to 2017.

METHODS

Data from the National Inpatient Sample were used to study hospitalization records for percutaneous vertebroplasty and kyphoplasty. Longitudinal projections of trends and outcomes, including mortality, post-procedural complications, length of stay, disposition, and total hospital charges were analyzed.

RESULTS

Following a period of decreased utilization from 2008 to 2012, hospitalizations for vertebroplasty and kyphoplasty plateaued after 2013. Total hospital charges and overall financial burden of hospitalizations for vertebroplasty and kyphoplasty increased to a peak of $1.9 billion (range $1.7-$2.2 billion) in 2017. Overall, 8% of procedures were performed in patients with a history of malignancy. In multivariable modeling, lung cancer (adjusted OR (aOR) 2.6 (range 1.4-5.1)) and prostate cancer (aOR 3.4 (range 1.2-9.4)) were associated with a higher risk of mortality. The New England region had the lowest frequency of routine disposition (14.1±1.1%) and the lowest average hospital charges ($47 885±$1351). In contrast, 34.0±0.8% had routine disposition in the West Central South region, and average hospital charges were as high as $99 836±$2259 in the Pacific region. The Mountain region had the lowest number of procedures (5365±272) and the highest mortality rate (1.2±0.3%).

CONCLUSION

National inpatient trends of vertebroplasty and kyphoplasty utilization remained stable after a period of decline from 2008 to 2012, while the financial burden of hospitalizations increased. Despite recent improvements in outcomes, significant regional variations persisted across the USA.

Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty

BACKGROUND

The economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture.

METHODS

The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated.

RESULTS

Hospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA.

CONCLUSION

Hospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.

Health insurance as a state institution: The effect of single-payer insurance on expenditures in OECD countries

A growing literature in comparative political economy and health economics has argued several cost-saving effects of a single-payer healthcare system. Despite this growing evidence, there has been no large-scale empirical examination of whether such an effect exists cross-nationally over time. This paper serves as the first attempt to find and calculate the extent to which healthcare spending is affected by the utilization of a single-payer scheme. I introduce an original dataset for OECD countries that measures when and where systems that qualify as single-payer exist, and employ it to test whether significant differences exist in health expenditures. Results demonstrate a significant difference between single- and multi-payer system expenditures. I estimate the utilization of a single-payer system is associated with decreased expenditure equal to 0.750 percentage-points of a nation's GDP. This would equate to the United States saving well over $1.5 trillion over ten years.

Why time poverty matters for individuals, organisations and nations

Over the last two decades, global wealth has risen. Yet material affluence has not translated into time affluence. Most people report feeling persistently 'time poor'-like they have too many things to do and not enough time to do them. Time poverty is linked to lower well-being, physical health and productivity. Individuals, organisations and policymakers often overlook the pernicious effects of time poverty. Billions of dollars are spent each year to alleviate material poverty, while time poverty is often ignored or exacerbated. In this Perspective, we discuss the societal, organisational, institutional and psychological factors that explain why time poverty is often under appreciated. We argue that scientists, policymakers and organisational leaders should devote more attention and resources toward understanding and reducing time poverty to promote psychological and economic well-being.

Financial Performance of SDG Mutual Funds Focused on Biotechnology and Healthcare Sectors

Measures favoring healthy lives among populations around the world are essential to reduce social inequalities. Mutual funds could play an important role funding these measures if they are able to attract socially concerned investors by improving their wealth. This study analyzes the financial performance of mutual funds focused on the biotechnology and healthcare sectors related to UN sustainable development goal 3 (SDG 3), comparing their risk-adjusted return with that achieved by conventional mutual funds. This study implements Carhart’s multifactor model and Bollen and Busse’s timing multifactor model on a sample of 34 biotechnology and 178 healthcare mutual funds and 4352 conventional mutual funds. The results show that biotechnology and healthcare mutual funds perform similarly, while both of them outperform conventional mutual funds. This outperformance of biotechnology and healthcare funds is driven by the superior stock-picking skills of their managers with regards to those of conventional fund managers, while managers of biotechnology, healthcare, and conventional mutual funds present similar poor market timing ability. Mutual funds specialized in biotechnology and healthcare sectors related to sustainable development goal 3 (SDG 3) outperform conventional mutual funds.

Check-in Kiosks in the Outpatient Clinical Setting: Fad or the Future?

OBJECTIVES

Check-in kiosks are increasingly used in health care. This project aims to assess the effects of kiosk use upon check-in duration, point of service (POS) financial returns, and patient satisfaction.

METHODS

Six kiosks were implemented in a large academic orthopedic clinic, and check-in duration for 8.5 months following implementation and POS returns for 10.5 months before and after implementation were analyzed. Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey and self-devised surveys recorded patient satisfaction.

RESULTS

Cumulatively, 28,636 kiosk-based patient encounters were analyzed. Compared with historical norms, check-in duration decreased 2 minutes, 47 seconds (P < 0.001). Daily gross and individual POS returns increased $532.13 and $1.89, respectively (P < 0.001). Satisfaction surveys were completed by 719 of 1376 consecutive patients (52% response rate), revealing 12% improvement (P < 0.001), but Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey responses demonstrated no change (P = 0.146, 0.928, and 0.336).

CONCLUSIONS

Kiosks offer to reduce check-in duration and increase POS revenue without negatively affecting patient satisfaction.

Surgeon Reimbursement Unchanged as Hospital Charges and Reimbursements Increase for Total Joint Arthroplasty

BACKGROUND

Despite increasing demands on physicians and hospitals to increase value and reduce unnecessary costs, reimbursement for healthcare services has been under downward pressure for several years. This study aimed to analyze the trend in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for total hip (THA) and knee arthroplasty (TKA).

METHODS

The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 56,228 patients who underwent primary THA and 117,698 patients who underwent primary TKA between 2005 and 2014. Two values were calculated: (1) the charge multiplier (CM), the ratio of hospital to surgeon charges and (2) the payment multiplier (PM), the ratio of hospital to surgeon payments. Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.

RESULTS

Hospital charges were significantly higher than surgeon charges and increased substantially for both THA (CM increased from 8.7 to 11.5, P < .0001) and TKA (CM increased from 7.9 to 11.4, P < .0001). PM followed a similar trend, increasing for both THA and TKA (P < .0001). LOS decreased significantly for both THA and TKA (P < .0001), while Charlson Comorbidity Index remained stable. Both CM (r² = 0.84 THA, 0.90 TKA) and PM (r² = 0.75 THA, 0.84 TKA) were strongly negatively associated with LOS.

CONCLUSION

Hospital charges and payments relative to surgeon charges and payments have increased substantially for THA and TKA despite stable patient complexity and decreasing LOS.

Health Care Administrative Costs in the United States and Canada, 2017

BACKGROUND

Before Canada's single-payer reform, its payment system, health costs, and number of health administrative personnel per capita resembled those of the United States. By 1999, administration accounted for 31% of U.S. health expenditures versus 16.7% in Canada. No recent comprehensive analyses of those costs are available.

OBJECTIVE

To quantify 2017 spending for administration by insurers and providers.

DESIGN

Analyses of government reports, accounting data that providers file with regulators, surveys of physicians, and census-collected data on employment in health care.

SETTING

United States and Canada.

MEASUREMENTS

Insurance overhead; administrative expenditures of hospitals, physicians, nursing homes, home care agencies, and hospices.

RESULTS

U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2-percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans.

LIMITATIONS

Estimates exclude dentists, pharmacies, and some other providers; accounting categories for the 2 countries differ somewhat; and methodological changes probably resulted in an underestimate of administrative cost growth since 1999.

CONCLUSION

The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance-based, multipayer system. The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden.

PRIMARY FUNDING SOURCE

None.

Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care

This paper is part of the American College of Physicians' policy framework to achieve a vision for a better health care system, where everyone has coverage for and access to the care they need, at a cost they and the country can afford. Currently, the United States is the only wealthy industrialized country that has not achieved universal health coverage. The nation's existing health care system is inefficient, unaffordable, unsustainable, and inaccessible to many. Part 1 of this paper discusses why the United States needs to do better in addressing coverage and cost. Part 2 presents 2 potential approaches, a single-payer model and a public choice model, to achieve universal coverage. Part 3 describes how an emphasis on value-based care can reduce costs.

Navigating the Shifting Terrain of US Health Care Reform-Medicare for All, Single Payer, and the Public Option

Policy Points "Medicare for All" is an increasingly common term in US health care reform debates, yet widespread confusion exists over its meaning. The various meanings of Medicare for All and other related terms reflect divergent political and philosophical assumptions about the preferred direction of health care reform, as well as the hybrid structure of the current Medicare program.

Patterns of Care and Costs for Older Patients With Colorectal Cancer at the End of Life: Descriptive Study of the United States and Canada

PURPOSE

End-of-life (EOL) cancer care is costly, with challenges regarding intensity and place of care. We described EOL care and costs for patients with colorectal cancer (CRC) in the United States and the province of Ontario, Canada, to inform better care delivery.

METHODS

Patients diagnosed with CRC from 2007 to 2013, who died of any cancer from 2007 to 2013 at age ≥ 66 years, were selected from the US SEER cancer registries linked to Medicare claims (n = 16,565) and the Ontario Cancer Registry linked to administrative health data (n = 6,587). We estimated total and resource-specific costs (2015 US dollars) from public payer perspectives over the last 360 days of life by 30-day periods, by stage at diagnosis (0-II, III, IV).

RESULTS

In all months, especially 30 days before death, higher percentages of SEER-Medicare than Ontario patients received chemotherapy (15.7% v 8.0%), and imaging tests (39.4% v 31.1%). A higher percentage of Ontario patients were hospitalized (62.5% v 51.0%), but 43.2% of hospitalized SEER-Medicare patients had intensive care unit (ICU) admissions versus 17.9% of hospitalized Ontario patients. Cost differences between cohorts were greater for patients with stage IV disease. In the last 30 days, mean total costs for patients with stage IV disease were $15,881 (SEER-Medicare) and $12,034 (Ontario) versus $19,354 and $17,312 for stage 0-II. Hospitalization costs were higher for SEER-Medicare patients ($11,180 v $9,434), with lower daily hospital costs in Ontario ($1,067 v $2,004).

CONCLUSION

These findings suggest opportunities for reducing chemotherapy and ICU use in the United States and hospitalizations in Ontario.

Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

IMPORTANCE

Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries.

OBJECTIVE

To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States.

DESIGN, SETTING, AND PARTICIPANTS

This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018.

EXPOSURES

Diagnostic imaging use.

MAIN OUTCOME AND MEASURES

Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures.

RESULTS

A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar.

CONCLUSIONS AND RELEVANCE

Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.

Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States

OBJECTIVE

Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost.

PATIENTS AND METHODS

Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs.

RESULTS

From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40-59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost.

CONCLUSION

aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.

Value-Based Care: A Review of Key Challenges and Opportunities Relevant to Medical Technology Innovators

Developed countries struggle with high healthcare spending, and cost is often cited as a barrier to the introduction of new patient care technologies. The core objective of this review article is to help familiarize medical technology innovators with trends in the health economic environment and the implications for the adoption of new technologies. We review and discuss this topic in language accessible to medical technology innovators. We assess macrolevel developments in healthcare spending and highlight measures already taken to control spending. We discuss practical implications for anyone involved in healthcare innovation. Two observations are central to this discussion: (1) the U.S. spends significantly more on healthcare per capita than any other developed country; (2) across developed countries, healthcare spending has risen steadily over the past two decades. Nevertheless, higher spending has not always led to improvements in health. As a result, innovators need to be prepared to navigate an outcomes-oriented and value-based environment that is being defined by the emerging requirements of various healthcare stakeholders. Practically, new products should aim to improve health outcomes at a cost deemed “good value” and/or reduce cost for one or multiple stakeholders. Opportunities also exist for tools that enable cost/outcomes tracking, which will help demonstrate value to providers, insurers, and patients.

Estimation of Association between Healthcare System Efficiency and Policy Factors for Public Health

Objective: To assess the association between the healthcare system’s efficiency and policy factors (the types of healthcare systems and various health policy indicators). Methods: In this study, a data envelopment analysis (DEA) with bootstrapping was applied to the healthcare system’s efficiency to correct the bias of efficiency scores and to rank countries appropriately. We analyzed data mainly from the OECD (Organization for Economic Co-operation and Development) Health Data from 2014. After obtaining the efficiency score result, we analyzed which policy factor caused the inefficiency of the healthcare system by Tobit Regression. Results: Based on five types of healthcare system classification, the result suggested that the social health insurance (e.g., Austria, Germany, Switzerland) showed the lowest efficiency score on average when compared to other types of systems, but evidence of a statistically significant difference in healthcare efficiency among four types of healthcare systems was not found. It was shown that the pure technological efficiency of the healthcare system was negatively influenced by two main factors: user choice for basic insurance coverage and degree of decentralization to sub-national governments. Conclusions: Our findings suggest that countries with relatively low healthcare system efficiency may learn from countries that implement policies related to a low level of user choice and a high level of centralization to achieve more economical allocation of their healthcare resources.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience

PURPOSE

To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods.

MATERIALS AND METHODS

This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers.

RESULTS

Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case.

CONCLUSIONS

The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

The Canadian health system's "administrative efficiency" is a problem

The Commonwealth Fund's "administrative efficiency" criterion ranks Canada poorly-sixth of the 11 countries compared. On two of the four patient-sourced measure used in this criterion, Canada was below the international average performance. For two of the three physician-sourced measures, Canada performs well but is significantly behind the best performing country. This suggests that Canada has room to improve, despite being better than average. Two opportunities for health leaders to make improvements are in relation to reducing the time physicians spend negotiating patient access to needed medications and reducing other administrative burdens related to claiming.

The Growing Executive-Physician Wage Gap in Major US Nonprofit Hospitals and Burden of Nonclinical Workers on the US Healthcare System

BACKGROUND

In an era of increasing healthcare costs, the number and value of nonclinical workers, especially hospital management, has come under increased study. Compensation of hospital executives, especially at major nonprofit medical centers, and the "wage gap" with physicians and clinical staff has been highlighted in the national news. To our knowledge, a systematic analysis of this wage gap and its importance has not been investigated.

QUESTIONS/PURPOSES

(1) How do wage trends compare between physicians and executives at major nonprofit medical centers? (2) What are the national trends in the wages and the number of nonclinical workers in the healthcare industry? (3) What do nonclinical workers contribute to the growth in national cost of healthcare wages? (4) How much do wages contribute to the growth of national healthcare costs? (5) What are the trends in healthcare utilization?

METHODS

We identified chief executive officer (CEO) compensation and chief financial officer (CFO) compensation at 22 major US nonprofit medical centers, which were selected from the US News & World Report 2016-2017 Hospital Honor Roll list and four health systems with notable orthopaedic departments, using publicly available Internal Revenue Service 990 forms for the years 2005, 2010, and 2015. Trends in executive compensation over time were assessed using Pearson product-moment correlation tests. As institution-specific compensation data is not available, national mean compensation of orthopaedic surgeons, pediatricians, and registered nurses was used as a surrogate. We chose orthopaedic surgeons and pediatricians for analysis because they represent the two ends of the physician-compensation spectrum. US healthcare industry worker numbers and wages from 2005 to 2015 were obtained from the Bureau of Labor Statistics and used to calculate the national cost of healthcare wages. Healthcare utilization trends were assessed using data from the Agency for Healthcare Quality and Research, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey. All data were adjusted for inflation based on 2015 Consumer Price Index.

RESULTS

From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 ± 0.9 million to USD 3.1 ± 1.7 million, or a 93% increase (R = 0.112; p = 0.009). The wage gap increased from 3:1 to 5:1 with orthopaedic surgeons, from 7:1 to 12:1 with pediatricians, and from 23:1 to 44:1 with registered nurses. We saw a similar wage-gap trend in CFO compensation. From 2005 to 2015, mean healthcare worker wages increased 8%. Management worker wages increased 14%, nonclinical worker wages increased 7%, and physician salaries increased 10%. The number of healthcare workers rose 20%, from 13 million to 15 million. Management workers accounted for 3% of this growth, nonclinical workers accounted for 27%, and physicians accounted for 5% of the growth. From 2005 to 2015, the national cost-burden of healthcare worker wages grew from USD 663 billion to USD 865 billion (a 30% increase). Nonclinical workers accounted for 27% of this growth, management workers accounted for 7%, and physicians accounted for 18%. In 2015, there were 10 nonclinical workers for every one physician. The cost of healthcare worker wages accounted for 27% of the growth in national healthcare expenditures. From 2005 to 2015, the number of inpatient stays decreased from 38 million to 36 million (a 5% decrease), the number of physician office visits increased from 964 million to 991 million (a 3% increase), and the number of emergency department visits increased from 115 million to 137 million (a 19% increase).

CONCLUSIONS

There is a fast-rising wage gap between the top executives of major nonprofit centers and physicians that reflects the substantial, and growing, cost of nonclinical worker wages to the US healthcare system. However, there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of nonclinical tasks in healthcare. Methods to reduce nonclinical work in healthcare may result in important cost-savings.

LEVEL OF EVIDENCE LEVEL

IV, economic and decision analysis.

Single-payer or a multipayer health system: a systematic literature review

OBJECTIVES

Healthcare systems worldwide are actively exploring new approaches for cost containment and efficient use of resources. Currently, in a number of countries, the critical decision to introduce a single-payer over a multipayer healthcare system poses significant challenges. Consequently, we have systematically explored the current scientific evidence about the impact of single-payer and multipayer health systems on the areas of equity, efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity.

STUDY DESIGN

This is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHODS

A search for relevant articles published in English was performed in March 2015 through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online through PubMed and Ovid, Health Technology Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible papers.

RESULTS

A total of 49 studies were included in the analysis; 34 studied clinical outcomes of patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field.

CONCLUSION

The single-payer system performs better in terms of healthcare equity, risk pooling and negotiation, whereas multipayer systems yield additional options to patients and are harder to be exploited by the government. A multipayer system also involves a higher administrative cost. The findings pertaining to the impact on efficiency and quality are rather tentative because of methodological limitations of available studies.

Administrative costs in health care-A scoping review

BACKGROUND

Administrative costs (AC) are a relevant spending category in health care, and several approaches exist on how to define and measure them. Based on available AC studies, this paper aims to provide a map for this multifaceted research topic.

METHODS

A scoping review was conducted using the databases MEDLINE, EconLit, and Business Source Premier. Literature was screened focussing on the research question: What is known about the methodology of AC research from scientific publications?

RESULTS

Definition concepts mostly rely on national cost documentations. The international cost reporting framework of the Systems of Health Accounts was a critical reference point in six studies. Indications on how to operationalise AC independently from periodical cost reports were suggested by ten publications. In this context, time and full time equivalents are the most common cost measurements.

CONCLUSIONS

The results indicate a lack of evidence regarding patients' perceptions of administrative issues in health care. Also, research on administrative impact on working conditions for health care employees beyond hospitals and physicians' offices is underrepresented. A systematic approach to reporting AC studies is needed. Reporting should include the appointment of entities actually empowered to change administrative resource usage. This would help to promote principles of a balanced administration.