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Diab YH, Saade G, Kawakita T. Continuous glucose monitoring vs. self-monitoring in pregnant individuals with type 1 diabetes: an economic analysis. Am J Obstet Gynecol MFM 2024:101413. [PMID: 38908796 DOI: 10.1016/j.ajogmf.2024.101413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy. OBJECTIVE To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus. STUDY DESIGN We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations. RESULTS In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15. CONCLUSION Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.
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Affiliation(s)
- Yara Hage Diab
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States.
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Nehme L, Horgan R, Waller J, Kumar P, Barake C, Huang JC, Saade G, Kawakita T. Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity. Am J Perinatol 2024; 41:e2878-e2885. [PMID: 37949098 DOI: 10.1055/s-0043-1776352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term. STUDY DESIGN We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs. RESULTS In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%. CONCLUSION Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity. KEY POINTS · The prevalence of obesity in the United States continues to rise.. · Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.. · Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals..
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Affiliation(s)
- Lea Nehme
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Rebecca Horgan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jerri Waller
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Priyanka Kumar
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia
| | - Carole Barake
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Jim C Huang
- Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
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Horný M, Chang D, Christensen EW, Rula EY, Duszak R. Decomposition of medical imaging spending growth between 2010 and 2021 in the US employer-insured population. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae030. [PMID: 38756926 PMCID: PMC10986240 DOI: 10.1093/haschl/qxae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 05/18/2024]
Abstract
Medical imaging, identified as a potential driver of unsustainable US health care spending growth, was subject to policies to reduce prices and use in low-value settings. Meanwhile, the Affordable Care Act increased access to preventive services-many involving imaging-for employer-sponsored insurance (ESI) beneficiaries. We used a large insurance claims database to examine imaging spending trends in the ESI population between 2010 and 2021-a period of considerable policy and benefits changes. Nominal spending on imaging increased 35.9% between 2010 and 2021, but as a share of total health care spending fell from 10.5% to 8.9%. The 22.5% growth of nominal imaging prices was below inflation, 24.3%, as measured by the Consumer Price Index. Other key contributors to imaging spending growth were increased use (7.4 percentage points [pp]), shifts toward advanced modalities (4.0 pp), and demographic changes (3.5 pp). Shifts in care settings and provider network participation resulted in 2.5-pp and 0.3-pp imaging spending decreases, respectively. In sum, imaging spending decreased as a share of all health care spending and relative to inflation, as intended by concurrent cost-containment policies.
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Affiliation(s)
- Michal Horný
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, GA 30322, United States
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA 30322, United States
| | - Daniel Chang
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, GA 30322, United States
| | - Eric W Christensen
- Harvey L. Neiman Health Policy Institute, Reston, VA 20191, United States
- Health Services Management, University of Minnesota, St. Paul, MN 55108, United States
| | - Elizabeth Y Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA 20191, United States
| | - Richard Duszak
- Department of Radiology, School of Medicine, University of Mississippi, Jackson, MS 39216, United States
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Sirur AJN, Pillai K R. Pricing of hospital services: evidence from a thematic review. HEALTH ECONOMICS, POLICY, AND LAW 2024:1-19. [PMID: 38314528 DOI: 10.1017/s1744133123000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
The management implications of pricing healthcare services, especially hospitals, have received insufficient scholarly attention. Additionally, disciplinary overlaps have led to scattered academic efforts in this domain. This study performs a thematic synthesis of the literature and applies retrospective analysis to hospital service pricing articles to address these issues. The study's inputs were sourced from well-known online repositories, using a structured search string and PRISMA flow chart to select the pertinent documents. Our thematic analysis of pricing literature encompasses: (a) comprehension of hospital service pricing nature; (b) pricing objectives, strategies and practices differentiation; (c) presentation of factors impacting hospital service pricing. We observe that hospital pricing is an intricate and unclear matter. The terms 'pricing strategies' and 'pricing practices' are often used interchangeably in academic literature. Hospital service pricing is influenced by costs, demand and supply factors, market structure, pricing regulation and third-party reimbursements. The study's findings provide policy implications for service pricing in hospitals, in addition to suggesting avenues for future research on hospital pricing.
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Affiliation(s)
- Andria J N Sirur
- Department of Commerce, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rajasekharan Pillai K
- Manipal Institute of Management, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Bernstein DN, Crowe JR. Price Transparency in United States' Health Care: A Narrative Policy Review of the Current State and Way Forward. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241255823. [PMID: 38798065 PMCID: PMC11129567 DOI: 10.1177/00469580241255823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
Health care price transparency is gaining momentum as a tangible policy intervention that can unleash market principles to increase competition, help begin to decrease U.S. health care expenditures, and provide Americans with access to affordable, high-quality health care. Indeed, pricing reform is required to facilitate patient shopping in health care. In this narrative policy review, we offer a brief history of health care price transparency efforts and an overview of the health care price transparency literature. Further, we highlight the current rules and legislative initiatives aimed at achieving the full potential of health care price transparency. Lastly, we offer key takeaways and highlight suggestions for future policy directions, including the need to ensure hospital and insurance compliance through more appropriate penalties and incentives, importance of reducing regulation to promote financial upside that can be obtained by both patients and providers who actively promote shopping for lower cost, higher quality health care goods and services, and the need for transparent and easily found quality metrics, including outcomes most important to patients, driven by physicians "on the ground" with patient input.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Business School, Soldiers Field, Boston, MA, USA
| | - Jonathan R. Crowe
- Center for Health Policy and Advocacy, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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James HO, Koller C, Nasuti LJ, Auerbach DI, Wilson IB. Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019. Health Serv Res 2023; 58:1172-1177. [PMID: 37177796 PMCID: PMC10622295 DOI: 10.1111/1475-6773.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVE To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.
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Affiliation(s)
- Hannah O. James
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
- Massachusetts Health Policy CommissionBostonMassachusettsUSA
| | - Christopher Koller
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Laura J. Nasuti
- Massachusetts Health Policy CommissionBostonMassachusettsUSA
| | | | - Ira B. Wilson
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
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Peterson C, Xu L, Grosse SD, Florence C. Professional Fees for U.S. Hospital Care, 2016-2020. Med Care 2023; 61:644-650. [PMID: 37943519 PMCID: PMC10653007 DOI: 10.1097/mlr.0000000000001900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND The latest comprehensive diagnosis-specific estimates of hospital professional fees relative to facility fees are from 2004 to 2012. OBJECTIVE Update professional fee ratio (PFR) estimates to improve cost analysis opportunities with hospital discharge data sources and compare them with previous PFR estimates. SUBJECTS 2016-2020 MarketScan inpatient admissions and emergency department (ED) treat and release claims. MEASURES PFR was calculated as total admission or ED visit payment divided by facility-only payment. This measure can be multiplied by hospital facility costs to yield a total cost estimate. RESEARCH DESIGN Generalized linear regression models controlling for selected patient and service characteristics were used to calculate adjusted mean PFR per admission or ED visit by health payer type (commercial or Medicaid) and by selected diagnostic categories representing all clinical diagnoses (Major Diagnostic Category, Diagnostic Related Group, and Clinical Classification Software Revised). RESULTS Mean 2016-2020 PFR was 1.224 for admissions with commercial payers (n = 6.7 million admissions) and 1.178 for Medicaid (n = 4.2 million), indicating professional payments on average increased total payments by 22.4% and 17.8%, respectively, above facility-only payments. This is a 9% and 3% decline in PFR, respectively, compared with 2004 estimates. PFR for ED visits during 2016-2020 was 1.283 for commercial payers (n = 22.2 million visits) and 1.415 for Medicaid (n = 17.7 million). This is a 12% and 5% decline in PFR, respectively, compared with 2004 estimates. CONCLUSIONS Professional fees comprise a declining proportion of hospital-based care costs. Adjustments for professional fees are recommended when hospital facility-only financial data are used to estimate hospital care costs.
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Affiliation(s)
- Cora Peterson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
| | - Likang Xu
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Curtis Florence
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1341-1348. [PMID: 37549887 DOI: 10.1016/j.jamda.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, ON, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paula A Rochon
- ICES, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, ON, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Nehme L, Ye P, Huang JC, Kawakita T. Decision and economic analysis of hostile abortion laws compared with supportive abortion laws. Am J Obstet Gynecol MFM 2023; 5:101019. [PMID: 37178721 DOI: 10.1016/j.ajogmf.2023.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws. OBJECTIVE This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies. STUDY DESIGN This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness. RESULTS In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%. CONCLUSION When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.
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Affiliation(s)
- Lea Nehme
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Nehme and Kawakita)
| | - Peggy Ye
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC (Dr Ye); Georgetown University School of Medicine, Washington, DC (Dr Ye)
| | - Jim C Huang
- Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan (Dr Huang)
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Nehme and Kawakita).
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Carlton EF, Becker NV, Moniz MH, Scott JW, Prescott HC, Chua KP. Out-of-Pocket Spending for Non-Birth-Related Hospitalizations of Privately Insured US Children, 2017 to 2019. JAMA Pediatr 2023; 177:516-525. [PMID: 36972040 PMCID: PMC10043803 DOI: 10.1001/jamapediatrics.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/13/2022] [Indexed: 03/29/2023]
Abstract
Importance Privately insured US children account for 40% of non-birth-related pediatric hospitalizations. However, there are no national data on the magnitude or correlates of out-of-pocket spending for these hospitalizations. Objective To estimate out-of-pocket spending for non-birth-related hospitalizations among privately insured children and identify factors associated with this spending. Design, Setting, and Participants This study is a cross-sectional analysis of the IBM MarketScan Commercial Database, which reports claims from 25 to 27 million privately insured enrollees annually. In the primary analysis, all non-birth-related hospitalizations of children 18 years and younger from 2017 through 2019 were included. In a secondary analysis focused on insurance benefit design, hospitalizations that could be linked to the IBM MarketScan Benefit Plan Design Database and were covered by plans with a family deductible and inpatient coinsurance requirements were analyzed. Main Outcomes and Measures In the primary analysis, factors associated with out-of-pocket spending per hospitalization (sum of deductibles, coinsurance, and copayments) were identified using a generalized linear model. In the secondary analysis, variation in out-of-pocket spending was assessed by level of deductible and inpatient coinsurance requirements. Results Among 183 780 hospitalizations in the primary analysis, 93 186 (50.7%) were for female children, and the median (IQR) age of hospitalized children was 12 (4-16) years. A total of 145 108 hospitalizations (79.0%) were for children with a chronic condition and 44 282 (24.1%) were covered by a high-deductible health plan. Mean (SD) total spending per hospitalization was $28 425 ($74 715). Mean (SD) and median (IQR) out-of-pocket spending per hospitalization were $1313 ($1734) and $656 ($0-$2011), respectively. Out-of-pocket spending exceeded $3000 for 25 700 hospitalizations (14.0%). Factors associated with higher out-of-pocket spending included hospitalization in quarter 1 compared with quarter 4 (average marginal effect [AME], $637; 99% CI, $609-$665) and lack of chronic conditions compared with having a complex chronic condition (AME, $732; 99% CI, $696-$767). The secondary analysis included 72 165 hospitalizations. Among hospitalizations covered by the least generous plans (deductible of $3000 or more and coinsurance of 20% or more) and most generous plans (deductible less than $1000 and coinsurance of 1% to 19%), mean (SD) out-of-pocket spending was $1974 ($1999) and $826 ($798), respectively (AME, $1123; 99% CI, $1069-$1179). Conclusions and Relevance In this cross-sectional study, out-of-pocket spending for non-birth-related pediatric hospitalizations were substantial, especially when they occurred early in the year, involved children without chronic conditions, or were covered by plans with high cost-sharing requirements.
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Affiliation(s)
- Erin F. Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nora V. Becker
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
| | - Michelle H. Moniz
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor
| | - John W. Scott
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Hallie C. Prescott
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Health Sciences Research and Development Center of Innovation, Ann Arbor, Michigan
| | - Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
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Blackburn CW, Du JY, Marcus RE. Medicare Payments to Hospitals and Physicians for Total Hip and Knee Arthroplasty Declined From 2009 to 2019. J Arthroplasty 2023; 38:419-423. [PMID: 36243278 DOI: 10.1016/j.arth.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Recent research has reported hospital payments for total hip arthroplasty (THA) and knee arthroplasty (TKA) from commercial payers to be increasing, despite increasing price pressure from the increasing scale and scope of alternative reimbursement schemes. Therefore, the primary objective of this study was to analyze the recent trends in Medicare payments to hospitals and surgeons for primary THA and TKA. METHODS The primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set (MEDPAR) for the years 2009, 2014, and 2019. A total of 331,721 patients undergoing primary elective THA and 742,476 patients undergoing primary elective TKA were included. Total Medicare payments and total hospital reimbursements, which included Medicare payments and patient copayments, were calculated. Physician fees were obtained from the Medicare physician fee schedule (MPFS) look-up tool. All financial data were inflation-adjusted. Patient comorbidities were identified as a measure of health status. The data were stratified by year and analyzed using descriptive statistics. RESULTS From 2009 to 2019, inflation-adjusted Medicare payments declined by 11.5% and total hospital reimbursements (Medicare payments plus copayments) declined by 6.5% for THA, while Medicare payments declined by 13.4%, and total hospital reimbursements declined by 7.7% for TKA. Over the same period, surgeons' fees declined by 13.1% for THA and 18.9% for TKA. CONCLUSION From 2009 to 2019, Medicare payments to hospitals and physicians declined markedly. Physician payments decreased faster than hospital payments. These results may have implications for the future viability of performing THA and TKA on Medicare patients.
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Affiliation(s)
- Collin W Blackburn
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jerry Y Du
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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12
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Buntin MB, Freed SS, Lai P, Lou K, Keohane LM. Trends in and Factors Contributing to the Slowdown in Medicare Spending Growth, 2007-2018. JAMA HEALTH FORUM 2022; 3:e224475. [PMID: 36459161 PMCID: PMC9719052 DOI: 10.1001/jamahealthforum.2022.4475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Importance After decades of rapid increase, Medicare per-beneficiary spending growth was historically low in the period leading up to the passage of the Affordable Care Act. In the years immediately following the legislation, Medicare expenditure growth slowed even further. Objective To evaluate factors contributing to the slowdown in Medicare per-beneficiary spending growth. Design, Setting, and Participants In this cross-sectional study, expected spending growth for 2012 to 2015 and 2016 to 2018 was predicted holding payment rates and population characteristics constant. By contrasting predicted and actual spending growth during these periods, the contribution of population vs payment factors to the Medicare spending slowdown was determined. Analyses included all Medicare fee-for-service beneficiaries aged 65 years and older, ranging from 30 to 35 million beneficiaries annually between 2007 and 2018. Data analyses were conducted from January 2018 to August 2018 and updated with new data in June 2021. Main Outcomes and Measures The main outcome included annual growth in total per-beneficiary spending. The roles of payment rate changes and differences in the Medicare population over time were considered, including demographic characteristics and numbers of chronic conditions. Results Between 2008 to 2011 and 2012 to 2015, the adjusted annual Medicare Parts A and B per-beneficiary spending growth rate declined from 3.3% to -0.1%. From 2016 to 2018, the mean annual Medicare spending growth rate rose relative to the previous period but remained lower than in the baseline period at 1.7% per year. This slowdown extended across all sectors within Parts A and B, except for physician-administered drugs offered under Part B. Changes in payment rates (including sequestration measures) and beneficiary characteristics explained 44% of the difference in overall per-beneficiary spending growth between 2007 to 2011 and 2012 to 2015, and 63% between 2007 to 2011 and 2016 to 2018. Conclusions and Relevance In this cross-sectional study of trends in spending growth per Medicare beneficiary aged 65 years or older, results suggested that Medicare payment policy, including sector-specific payment rate changes and sequestration, will be a critical determinant of whether the Medicare spending growth slowdown persists.
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Affiliation(s)
- Melinda B. Buntin
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Salama S. Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Pikki Lai
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee,Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Klara Lou
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura M. Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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13
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Michaud JB, Zhuang T, Shapiro LM, Cohen SA, Kamal RN. Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis. J Hand Surg Am 2022; 47:1057-1067. [PMID: 35985865 DOI: 10.1016/j.jhsa.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/29/2022] [Accepted: 06/15/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs. METHODS Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service. RESULTS The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs. CONCLUSIONS Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs. CLINICAL RELEVANCE To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.
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Affiliation(s)
- John B Michaud
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA
| | - Samuel A Cohen
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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14
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Shih YCT, Xu Y, Bradley C, Giordano SH, Yao J, Yabroff KR. Costs Around the First Year of Diagnosis for 4 Common Cancers Among the Privately Insured. J Natl Cancer Inst 2022; 114:1392-1399. [PMID: 36099068 PMCID: PMC9552304 DOI: 10.1093/jnci/djac141] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/03/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We estimated trends in total and out-of-pocket (OOP) costs around the first year of diagnosis for privately insured nonelderly adult cancer patients. METHODS We constructed incident cohorts of breast, colorectal, lung, and prostate cancer patients diagnosed between 2009 and 2016 using claims data from the Health Care Cost Institute. We identified cancer-related surgery, intravenous (IV) systemic therapy, and radiation and calculated associated total and OOP costs (in 2020 US dollars). We assessed trends in health-care utilization and cost by cancer site with logistic regressions and generalized linear models, respectively. RESULTS The cohorts included 105 255 breast, 23 571 colorectal, 11 321 lung, and 59 197 prostate cancer patients. For patients diagnosed between 2009 and 2016, total mean costs per patient increased from $109 544 to $140 732 for breast (29%), $151 751 to $168 730 for lung (11%) or $53 300 to $55 497 for prostate (4%) cancer were statistically significant. Increase for colorectal cancer (1%, $136 652 to $137 663) was not statistically significant (P = .09). OOP costs increased to more than 15% for all cancers, including colorectal, to more than $6000 by 2016. Use of IV systemic therapy and radiation statistically significantly increased, except for lung cancer. Cancer surgeries statistically significantly increased for breast and colorectal cancer but decreased for prostate cancer (P < .001). Total costs increased statistically significantly for nearly all treatment modalities, except for IV systemic therapy in colorectal and radiation in prostate cancer. CONCLUSIONS Rising costs of cancer treatments, compounded with greater cost sharing, increased OOP costs for privately insured, nonelderly cancer patients. Policy initiatives to mitigate financial hardship should consider cost containment as well as insurance reform.
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Affiliation(s)
- Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Xu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Bradley
- Department of Health Systems, Management & Policy, University of Colorado Comprehensive Cancer Center and Colorado School of Public Health, Aurora, CO, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James Yao
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Robin Yabroff
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA, USA
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15
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Sen AP, Singh Y, Anderson GF. Site-based payment differentials for ambulatory services among individuals with commercial insurance. Health Serv Res 2022; 57:1165-1174. [PMID: 35041209 PMCID: PMC9441285 DOI: 10.1111/1475-6773.13935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/24/2021] [Accepted: 12/21/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare prices paid by commercial insurers for ambulatory services in physician office and hospital outpatient settings. DATA SOURCES MarketScan Commercial Claims and Encounters database obtained from Truven Health Analytics. STUDY DESIGN We examined ambulatory service claims for a sample of privately insured individuals who were continuously enrolled in a health maintenance organization plan, preferred provider organization plan, high-deductible/consumer-driven health plan, or exclusive provider organization plan in 2018. We categorized services into five categories: Evaluation & Management, Medical Services & Procedures, Pathology/Lab, Radiology, and Surgical. We identified services commonly provided in both outpatient and office settings and computed the price differential between outpatient and office services overall and for each service category, controlling for observable patient characteristics and geography. DATA COLLECTION We examined 89 services (defined by Current Procedural Terminology [CPT] code) that were provided in both office and outpatient settings in our sample (102.7 million claims, 8.3 million individuals). PRINCIPAL FINDINGS Adjusting for patient and geographic characteristics and across all services, total payment for an ambulatory service was, on average, 145% higher in a hospital outpatient department than the same service in a physician office. Out-of-pocket spending was 109% higher. Price differences between outpatient and office services were highest for pathology/laboratory services. Patients receiving services in outpatient departments had higher mean risk scores and received more services on the date of their visit (in addition to the index CPT being studied) than patients receiving the same index CPT in a physician's office. CONCLUSIONS Payments in hospital outpatient departments were significantly higher than payments for the same services in physician offices among commercially insured patients. Policies such as site-neutral payment would lower costs and could reduce incentives for further consolidation in health care markets. Care must be given to adjusting for patient severity across settings.
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Affiliation(s)
- Aditi P. Sen
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Present address:
Health Care Cost Institute, 1100 G Street NWWashington, DC 20005USA
| | - Yashaswini Singh
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Gerard F. Anderson
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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16
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Gil K, Abbasi S, Mehta K, McClune B, Sborov D, Ahmed N, Abdallah AO, Ganguly S, McGuirk J, Shune L, Mohyuddin GR. Trends in Inpatient Chemotherapy Hospitalizations, Cost and Mortality for Patients with Acute Leukemias and Myeloma. Clin Hematol Int 2022; 4:56-59. [PMID: 35950203 PMCID: PMC9358787 DOI: 10.1007/s44228-022-00003-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/24/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kellen Gil
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Saqib Abbasi
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Kathan Mehta
- Department of Oncology, Kansas University Medical Center, Kansas City, USA
| | - Brian McClune
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, USA
| | - Douglas Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, USA
| | - Nausheen Ahmed
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Al-Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Siddhartha Ganguly
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Joseph McGuirk
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Leyla Shune
- Department of Hematological Malignancies and Cellular Therapeutics, Kansas University Medical Center, Kansas City, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, USA
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17
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Keller DS. Is the quantitative faecal immunochemical test (qFIT) ready for prime time in the US? Colorectal Dis 2022; 24:558-561. [PMID: 35435298 DOI: 10.1111/codi.16156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University of California at Davis Medical Center, Sacramento, CA, USA
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18
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Derlet RW, McNamara RM, Tomaszewski C. Corporate Control of Emergency Departments: Dangers from the Growing Monster. J Emerg Med 2022; 62:675-684. [PMID: 35400510 DOI: 10.1016/j.jemermed.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Corporate control in emergency departments (EDs) has increased during the past 20 years through hospital consolidation and the growth of ED contract management groups. OBJECTIVES To describe the growing corporate influence in the practice of emergency medicine and associated dangers to the public's safety and well-being. DISCUSSION Hospital systems through mergers and acquisitions have created regional monopolies providing them the power to charge high fees, which can lead to economic hardship for patients. Hospitals have also increasingly employed physicians and can exert influence over their practice to further increase profits. ED contract management groups (CMGs) obtain the exclusive contract for emergency services and gain control over the livelihood of emergency physicians, decreasing their autonomy and inserting the business interest into the physician-patient relationship, and this may result in harm to patients. Safety issues identified by emergency physicians may not be articulated for fear of being fired, and protocols may direct physicians to order unneeded testing and encourage unnecessary hospital admissions to make higher profits. Of additional concern, some CMGs are involved in graduate emergency medicine education, exposing physicians in training to corporate influence during their formative years. CONCLUSIONS Given the potential harm to patients due to corporate influence, there must be serious consideration for legislative or regulatory solutions regarding the increasing corporate control of emergency medicine in the United States.
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Affiliation(s)
- Robert W Derlet
- Department of Emergency Medicine, University of California, Davis, Sacramento, California.
| | - Robert M McNamara
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Christian Tomaszewski
- Department of Emergency Medicine, University of California San Diego, San Diego, California
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19
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The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital. J Am Acad Orthop Surg 2022; 30:e59-e66. [PMID: 34288892 DOI: 10.5435/jaaos-d-21-00293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/20/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The functional disability after amputation is tremendous and imposes a high economic burden on patients and health systems. The current literature on the costs of amputation has been limited to the index hospitalization or a short time window around the amputation procedure, which covers a small percentage of the total costs. METHODS We conducted a retrospective cohort study of patients who underwent lower extremity amputations at a single urban public level 1 trauma hospital. Resource utilization and healthcare costs 1 year before and 1 year after the index amputation were examined. Hospitalization costs were estimated using cost center-based cost-to-charge ratios for the 2-year follow-up. RESULTS The sample comprised 90 patients (73 men and 17 women) with a mean age of 55.9 years (SD, 9.9). Most amputations were secondary to diabetes (74%) and vascular disease in the absence of diabetes (22%). During the 2-year window around the index amputation, patients had an average of 2.7 admissions (SD, 2.3), mean index length of stay of 14.6 days (SD, 22.3), and a mean cumulative length of stay of 31.3 days (SD, 43.4). The patients had a mean of 2.3 (SD, 3.2) additional procedures performed on their amputated limb. Twenty-one patients (23%) required additional proximal amputations, with an average change of 2.2 (SD, 1.6) levels. The mean cost, per patient, of the index hospitalization was $51,481. Over the 2-year period, the mean cost of hospitalizations was $114,292 per patient with a total cost, summed over the cohort, of $10,286,250. Approximately 64% of the total cost went uncompensated. DISCUSSION Over a 2-year window, amputees endured multiple procedures, readmissions, and reamputations, leading to high healthcare costs. Further research into resource-conscious interventions and programs is needed to control the burdens faced by amputees and the health systems that care for them.
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20
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is associated with improved patient experience while reducing overall costs without compromising patient safety. Patient-centered care is crucial for further expansion and success of ambulatory surgery because it is associated with superior patient experience and improved patient satisfaction. This article discusses the approach to improving patient-centered care and patient-reported outcomes (PROs). RECENT FINDINGS It is necessary to recognize that each patient is different and may have different needs and preferences. Patient education and shared decision-making are critical components of patient-centered care. Shared decision-making emphasizes patient engagement in an effort to improve PROs. Implementation of enhanced recovery after surgery principles in ambulatory surgery is necessary to improve PROs. SUMMARY Delivery of patient-centered care will require modification of the current approach to perioperative care. It is imperative to measure PROs by implementing a comprehensive continuous quality improvement program.
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Affiliation(s)
- Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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21
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Coleman DL, Joiner KA. Physician Incentive Compensation Plans in Academic Medical Centers: The Imperative to Prioritize Value. Am J Med 2021; 134:1344-1349. [PMID: 34343514 DOI: 10.1016/j.amjmed.2021.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 06/20/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
The emphasis on clinical volume in physician compensation plans has diminished professional vitality in academic medical centers and increased the cost of health care. Physician incentive compensation plans that focus on clinical volume can distort clinical encounters and fail to incorporate the professionalism and intrinsic motivators of clinicians. We assert herein that physician incentive compensation plans should reward clinical value (quality/cost) rather than clinical volume. The recommended change is compelled by the tenets of medical professionalism, the need to cultivate meaning in clinical practice, and the urgent financial and moral imperatives to improve health outcomes and reduce cost. The design of physician incentive compensation plans should incorporate accurate and valid measures of quality and cost, behavioral economic considerations, transparency and equity, prospective assessment of the impact on key outcomes, and flexible elements that encourage innovation and preserve fidelity to unique practice circumstances. Physicians should be recognized in compensation plans for enhancing the value of care, inspiring and educating the future clinical workforce, and improving public health through discovery.
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Affiliation(s)
- David L Coleman
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Mass.
| | - Keith A Joiner
- Scholarly Projects, University of Arizona College of Medicine, Tucson
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22
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Ganguli I, Morden NE, Yang CWW, Crawford M, Colla CH. Low-Value Care at the Actionable Level of Individual Health Systems. JAMA Intern Med 2021; 181:1490-1500. [PMID: 34570170 PMCID: PMC8477305 DOI: 10.1001/jamainternmed.2021.5531] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. OBJECTIVES To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. MAIN OUTCOMES AND MEASURES Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. RESULTS Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs -0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs -0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs -0.06 [95% CI, -0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with -0.09 [95% CI, -0.26 to 0.08] for the Northeast and -0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs -0.24 [95% CI, -0.36 to -0.12] for areas below the median level of spending; P < .001). CONCLUSIONS AND RELEVANCE The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
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23
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Pany MJ, Chernew ME, Dafny LS. Regulating Hospital Prices Based On Market Concentration Is Likely To Leave High-Price Hospitals Unaffected. Health Aff (Millwood) 2021; 40:1386-1394. [PMID: 34495728 DOI: 10.1377/hlthaff.2021.00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Concern about high hospital prices for commercially insured patients has motivated several proposals to regulate these prices. Such proposals often limit regulations to highly concentrated hospital markets. Using a large sample of 2017 US commercial insurance claims, we demonstrate that under the market definition commonly used in these proposals, most high-price hospitals are in markets that would be deemed competitive or "moderately concentrated," using antitrust guidelines. Limiting policy actions to concentrated hospital markets, particularly when those markets are defined broadly, would likely result in poor targeting of high-price hospitals. Policies that target the undesired outcome of high price directly, whether as a trigger or as a screen for action, are likely to be more effective than those that limit action based on market concentration.
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Affiliation(s)
- Maximilian J Pany
- Maximilian J. Pany is an MD-PhD candidate in health policy at Harvard Medical School and Harvard Business School, in Boston, Massachusetts
| | - Michael E Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - Leemore S Dafny
- Leemore S. Dafny is the Bruce V. Rauner Professor of Business Administration at Harvard Business School and the Harvard Kennedy School, Harvard University, in Cambridge, Massachusetts
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Shaikh N, Umscheid J, Rizvi S, Bhatt P, Vasudeva R, Yagnik P, Bhatt N, Donda K, Dapaah-Siakwan F. National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children. Hosp Pediatr 2021; 11:662-670. [PMID: 34187789 DOI: 10.1542/hpeds.2020-005794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Although a growing body of evidence suggests that early transition to oral antimicrobial therapy is equally efficacious to prolonged intravenous antibiotics for treatment of acute pediatric osteomyelitis, little is known about the pediatric trends in peripherally inserted central catheter (PICC) placements. Using a national database, we examined incidence rates of pediatric hospitalizations for acute osteomyelitis in the United States from 2007 through 2016, as well as the trends in PICC placement, length of stay (LOS), and cost associated with these hospitalizations. METHODS This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 through 2016. Patients ≤18 years of age with acute osteomyelitis were identified by using appropriate diagnostic codes. Outcomes measured included PICC placement rate, LOS, and inflation-adjusted hospitalization costs. Weighted analysis was reported, and a hierarchical regression model was used to analyze predictors. RESULTS The annual incidence of acute osteomyelitis increased from 1.0 to 1.8 per 100 000 children from 2007 to 08 to 2015 to 16 (P < .0001), whereas PICC placement rates decreased from 58.8% to 5.9% (P < .0001). Overall, changes in LOS and inflation-adjusted hospital costs were not statistically significant. PICC placements and sepsis were important predictors of increased LOS and hospital costs. CONCLUSIONS Although PICC placement rates for acute osteomyelitis significantly decreased in the face of increased incidence of acute osteomyelitis in children, LOS and hospital costs for all hospitalizations remained stable. However, patients receiving PICC placements had longer LOS. Further studies are needed to explore the long-term outcomes of reduced PICC use.
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Affiliation(s)
- Nadia Shaikh
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Illinois;
| | - Jacob Umscheid
- School of Medicine, University of Kansas, Wichita, Kansas
| | - Syed Rizvi
- Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | - Parth Bhatt
- United Hospital Center, Bridgeport, West Virginia
| | | | - Priyank Yagnik
- School of Medicine, University of Kansas, Wichita, Kansas
| | - Neel Bhatt
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Keyur Donda
- Department of Pediatrics, University of South Florida, Tampa, Florida; and
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Weng KY, Xia F, Lin WQ, Wang YB. Performance Comparison of Public Hospitals Between 2014 and 2018 in Different Regions of Guangdong Province, China, Following 2017 Medical Service Price Reforms. Front Public Health 2021; 9:701201. [PMID: 34277559 PMCID: PMC8277996 DOI: 10.3389/fpubh.2021.701201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
This study analyzed performance of public hospitals and regional differences in performance following reform of medical service prices in Guangdong province, China. From three cities in four regions, we randomly selected a total of 12 traditional Chinese medicine hospitals and 12 general tertiary hospitals. Six questionnaires were completed by the hospitals, using 2014-2018 internal data. Principal components analysis was used to compare performances of the hospitals and regions following price reform. The extent to which medical service prices were adjusted varied considerable for different procedures in the same region and for the same category of procedures among regions. After reform, compensation for medical services in public hospitals reached the target of 80%, except in the Western region. However, annual growth of costs to patients was generally above 4%; the burden on patients was not alleviated by fee control. Reforms were more effective for comprehensive than Chinese traditional medicine hospitals. Performance scores of general hospitals in the Pearl River Delta, Eastern, Western, and Northern regions were 1.24, 1.16, -0.22, and -1.01, respectively. This is consistent with ranking by level of economic development of each region. The government should implement a regional medical service pricing mechanism. Additionally, comprehensive and traditional Chinese medicine hospitals should each have appropriate pricing policies. Future policies should focus on controlling costs incurred by patients.
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Affiliation(s)
- Kai-Yuan Weng
- School of Public Management and Policy, China University of Mining and Technology, Xuzhou, China.,College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Feng Xia
- Medical Insurance Office, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Qi Lin
- College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yi-Bao Wang
- School of Public Management and Policy, China University of Mining and Technology, Xuzhou, China
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Peckham ME, Anzai Y, Shah LM, de Gennaro G, Costello JA, Hutchins TA. Shifting Spine Interventional Pain Injections From the Hospital to a Clinic Setting: Increased Efficiency and Decreased Health System Costs. J Am Coll Radiol 2021; 18:1229-1234. [PMID: 34216558 DOI: 10.1016/j.jacr.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Spine interventional pain injections have dramatically increased in volume in the past three decades. High referral volumes at our institution necessitated using both a hospital-based interventional suite and a clinic-based suite scheduled on a first-come, first-served basis. We sought to determine whether the clinic-based suite provided benefits in efficiency and health system cost in comparison with the hospital suite without compromising quality of care. METHODS To investigate differences between outpatient procedures performed in hospital-based procedure rooms (HBPRs) and clinic-based procedure rooms (CBPRs), we reviewed all consecutive outpatient spine interventional pain procedures performed by the interventional neuroradiology service over a 12-month period. We analyzed procedure complexity, fluoroscopic times, procedural times, patient wait times, and health system costs for each case, as well as any complications. RESULTS Our analysis demonstrated similar procedural complexity between sites with decreased average fluoroscopic time (112 seconds versus 163 seconds, P = .002), procedural time (17 min versus 28 min, P < .001), and wait time (20 min versus 38 min, P < .001) in the CBPR versus the HBPR. In cases without trainee involvement, procedural and wait times were decreased (P < .001, P = .008) with no difference in fluoroscopy time (P = .18). There were no complications at either site. The analysis of cost to the health system demonstrated that procedures in the HBPR cost >14 times the amount to perform than in the CBPR. DISCUSSION Performing spine interventional pain procedures in a CBPR adds value by decreasing procedural, fluoroscopic, wait times, and health system cost compared with an HBPR without compromising safety.
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Affiliation(s)
- Miriam E Peckham
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah.
| | - Yoshimi Anzai
- Associate Chief Medical Quality Officer, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | - Lubdha M Shah
- Director of Spine Imaging, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | | | - Justin A Costello
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | - Troy A Hutchins
- Chief Value Officer, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
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Friedlander DF, Krimphove MJ, Cole AP, Marchese M, Lipsitz SR, Weissman JS, Schoenfeld AJ, Ortega G, Trinh QD. Where Is the Value in Ambulatory Versus Inpatient Surgery? Ann Surg 2021; 273:909-916. [PMID: 31460878 DOI: 10.1097/sla.0000000000003578] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures. SUMMARY BACKGROUND DATA Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery. METHODS All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Inverse probability of treatment weighting-adjusted gamma generalized linear and logistic regression was employed to compare costs and 30-day readmission between inpatient and ambulatory-based surgery, respectively. RESULTS Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (P < 0.001 for all). Adjusted odds of experiencing a 30-day readmission after thyroidectomy [odds ratio (OR) 0.70, 95% confidence interval (CI), 0.53-0.93; P = 0.03], hernia repair (OR 0.28, 95% CI, 0.20-0.40; P < 0.001), and laparoscopic cholecystectomy (OR 0.37, 95% CI, 0.32-0.43; P < 0.001) were lower in the ambulatory versus inpatient setting. Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (OR 0.63, 95% CI, 0.31-1.26; P = 0.19). CONCLUSIONS Ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.
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Affiliation(s)
- David F Friedlander
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marieke J Krimphove
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Alexander P Cole
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA
| | - Maya Marchese
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gezzer Ortega
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Fendrick AM, Brixner D, Rubin DT, Mease P, Liu H, Davis M, Mittal M. Sustained long-term benefits of patient support program participation in immune-mediated diseases: improved medication-taking behavior and lower risk of a hospital visit. J Manag Care Spec Pharm 2021; 27:1086-1095. [PMID: 33843252 PMCID: PMC10394214 DOI: 10.18553/jmcp.2021.20560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Patient support programs (PSPs) improve medication-taking behavior in the first 12 months of treatment for patients with immune-mediated diseases, but it is unknown if these benefits are sustained. As immune-mediated diseases continue to increase in prevalence and economic burden, understanding the potential value of PSPs in helping patients adhere to their long-term treatment plan and avoid costly hospital visits is crucial. Launched nationally in 2015, HUMIRA Complete (a PSP for adalimumab patients) provides an opportunity to study long-term effects of PSP participation, including the impact on medication-taking behavior and hospital visits. OBJECTIVE: To evaluate the sustained relationship between PSP participation, long-term medication-taking behavior, and hospital visits. METHODS: A longitudinal, retrospective matched-cohort study was conducted of patients initiating adalimumab between January 2015 and February 2016 with or without enrolling in the PSP, using patient-level data from the HUMIRA Complete PSP linked with Symphony Health claims. The sample included adult, commercially insured patients diagnosed with an indicated disease who were biologic-naive and had data available for ≥ 6 months before and ≥ 12 months after initiating adalimumab. Adherence (proportion of days covered) and hospital visits were assessed at 12, 24, and 36 months for patients with sufficient follow-up data. Multivariable generalized models estimated differences between cohorts, controlling for baseline characteristics and hospital visits. Duration of persistence and time to a hospital visit were compared using Kaplan-Meier analyses. Hazard ratios were estimated using multivariable Cox proportional hazards models. RESULTS: The matched cohort included 2,268 patients (1,134 per cohort), and patient attrition was similar across cohorts. The PSP cohort consistently demonstrated higher adalimumab adherence than the non-PSP cohort at 12 (64.8% vs. 50.1%, P < 0.0001; 29% greater), 24 (49.4% vs. 38.4%; P < 0.0001; 29% greater), and 36 (39.4% vs. 35.1%; P = 0.02; 12% greater) months. PSP participation was associated with a 30% lower hazard of discontinuation (P < 0.0001), and median duration of persistence was 4.8 months longer for the PSP cohort (13.2 vs. 8.4 months; P < 0.0001). The PSP cohort had lower rates of hospital visits at 12 (30% vs. 37%; P < 0.001; 19% lower), 24 (44% vs. 53%; P = 0.01; 17% lower), and 36 (55% vs. 65%; P < 0.01; 16% lower) months, and PSP participation was associated with a 25% lower hazard of a hospital visit (P < 0.0001). Median time to a hospital visit was 10.8 months longer for the PSP cohort (32.7 vs. 21.9 months; P < 0.0001). Findings were consistent across therapeutic areas: hazard of a hospital visit was 28%, 27%, and 37% lower for rheumatology, gastroenterology, and dermatology patients participating in the PSP (all P < 0.05). CONCLUSIONS: Patients with immune-mediated diseases receiving adalimumab and utilizing this PSP had improved long-term medication-taking behavior and lower risk of hospital visits, demonstrating the potential of PSPs to improve patient outcomes and lower the burden to the health care system. DISCLOSURES: Design, study conduct, and financial support for the study were provided by AbbVie Inc., which participated in the interpretation of data, review, and approval of the manuscript. Fendrick has received personal fees from Merck, AstraZeneca, Trizetto, Amgen, Lilly, AbbVie, Johnson & Johnson, and Sanofi; grants from the National Pharmaceutical Council, PhRMA, the Gary and Mary West Health Foundation, the states of New York and Michigan, the Laura and John Arnold Foundation, the Robert Wood Johnson Foundation, and the Agency for Healthcare Research and Quality; and equity in Zansors, Sempre Health, Wellth, and V-BID Health. Brixner has received consulting fees from AbbVie, Novartis, Xcenda, Elevar Therapeutics, Sanofi, UCB Pharma, and the Millcreek Outcomes Group. Rubin has received consulting fees from AbbVie, Abgenomics, Allergan Inc., Amgen, Celgene Corporation, Forward Pharma, Genentech/Roche, Janssen Pharmaceuticals, Merck & Co., Miraca Life Sciences, Mitsubishi Tanabe Pharma Development America, Napo Pharmaceuticals, Pfizer, Salix Pharmaceuticals Inc., Samsung Bioepis, Sandoz Pharmaceuticals, Shire, Takeda, and Target Pharmaceuticals; and research support from AbbVie, Genentech/Roche, Janssen Pharmaceuticals, Prometheus Laboratories, Shire, Takeda, and UCB Pharma. Mease has received grant/research support from AbbVie, Amgen, BMS, Celgene, Janssen, Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB; consulting fees from AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Galapagos, Genentech, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, SUN Pharma, and UCB; and has served on the speakers bureau for AbbVie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB. Liu has no financial conflict of interest. Davis is an employee of Medicus Economics, which received payment from AbbVie to participate in this research. Mittal is an employee and stockholder of AbbVie. This study used a cohort of patients previously described in Brixner D, Rubin DT, Mease P, et al. Patient support program increased medication adherence with lower total health care costs despite increased drug spending. J Manag Care Spec Pharm. 2019 Jul;25(7):770-79 (doi: 10.18553/jmcp.2019.18443). As such, the sample selection and select baseline characteristics and 12-month outcomes have been published previously; however, the hospital visit outcomes and the longer-term medication-taking behavior outcomes have not been previously published or presented.
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Affiliation(s)
| | - Diana Brixner
- University of Utah College of Pharmacy, Salt Lake City
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL
| | - Philip Mease
- Swedish Medical Center/Providence St. Joseph Health and University of Washington School of Medicine, Seattle, WA
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Abstract
OBJECTIVE To examine temporal trends of OOP expenses, total payments, facility fees, and professional fees for outpatient surgery. SUMMARY BACKGROUND DATA Approximately 48 million outpatient surgeries are performed annually with a limited financial understanding of these procedures. High OOP expenses may influence treatment decisions, delay care, and cause financial burden for patients. METHODS We conducted a retrospective cohort study of patients with employer-sponsored insurance undergoing common outpatient surgical procedures (cholecystectomy, cataract surgery, meniscectomy, muscle/tendon procedures, and joint procedures) from 2011 to 2017. Total payments for surgical encounters paid by the insurer/employer and patient OOP expenses were calculated. We used multivariable linear regression to predict total payments and OOP expenses, with costs adjusted to the 2017 US dollar. RESULTS We evaluated 5,261,295 outpatient surgeries (2011-2017). Total payments increased by 29%, with a 53% increase in facility fees and no change in professional fees. OOP expenses grew by 50%. After controlling for procedure type, procedures performed in ambulatory surgery centers conferred an additional $2019 in predicted total payments (95%CI:$2002-$2036) and $324 in OOP expenses (95%CI:$319-$328) compared to predicted cost for office-based procedures. Hospital-based procedures cost an additional $2649 in predicted total payments (95%CI:$2632-$2667) and $302 in predicted OOP expenses (95%CI:$297-$306) compared to office procedures. CONCLUSION Increases in outpatient surgery total payments were driven primarily by facility fees and OOP expenses. OOP expenses are rising faster than total payments, highlighting the transition of costs to patients. Healthcare cost reduction policies should consider the largest areas of spending growth such as facility fees and OOP expenses to minimize the financial burden placed on patients.
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Mouawad NJ, Malgor RD. Vascular Surgeons Should be Valued by Contemporarily Derived Productivity Metrics. Ann Vasc Surg 2021; 73:e3-e4. [PMID: 33485906 DOI: 10.1016/j.avsg.2021.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Nicolas J Mouawad
- Division of Vascular and Endovascular Surgery, McLaren Health System - Bay Region, Bay City, MI; Michigan State University, East Lansing, MI.
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO
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Lopez CD, Boddapati V, Anderson MJJ, Ahmad CS, Levine WN, Jobin CM. Recent trends in Medicare utilization and surgeon reimbursement for shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:120-126. [PMID: 32778384 DOI: 10.1016/j.jse.2020.04.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/03/2020] [Accepted: 04/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent efforts to contain health care costs and move toward value-based health care have intensified, with a continued focus on Medicare expenditures, especially for high-volume procedures. As total shoulder arthroplasty (TSA) volume continues to increase, especially within the Medicare population, it is important for orthopedic surgeons to understand recent trends in the allocation of health care expenditures and potential effects on reimbursements. The purpose of this study was to evaluate trends in annual Medicare utilization and provider reimbursement rates for shoulder arthroplasty procedures between 2012 and 2017. METHODS This study tracked annual Medicare claims and payments to shoulder arthroplasty surgeons via publicly available databases and aggregated data at the county level. Descriptive statistics were used to evaluate trends in procedure volume, utilization rate (per 10,000 Medicare beneficiaries), and reimbursement rate. We used adjusted multiple linear regression models to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percentage Medicare population, and race and ethnicity demographics) and procedure volume, utilization rate, and reimbursement rate. RESULTS Between 2012 and 2017, there was an 81.3% increase in primary TSA volume and 55.5% increase in primary TSA utilization. The Midwest and South had higher utilization rates than the Northeast and West (P < .001). TSA utilization rates in metropolitan areas were significantly higher than in rural areas (P < .001). Utilization rates for primary TSA procedures also had a significant negative association with poverty rate (P < .001). Regarding reimbursements, the Medicare payment per TSA case decreased from 2012 to 2017, with overall inflation-adjusted decreases of 7.1% and 11.8% for primary and revision cases, respectively. TSAs performed in metropolitan areas received significantly higher reimbursements per case than TSAs performed in rural areas ($1108.05 and $1066.40, respectively; P = .002). Furthermore, reimbursements per case were on average higher in the Northeast and West than in the South and Midwest (P < .001). CONCLUSIONS Our study confirms that although TSA volume and per capita utilization have increased dramatically since 2012, Medicare Part B reimbursements to surgeons have continued to fall even after the adoption of bundled-payment models for orthopedic procedures. Cost-containment efforts continue to focus on Medicare reimbursements to surgeons, although other expenditures such as hospital payments and operational and implant costs must also be evaluated as part of an overall transition to value-based health care.
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Affiliation(s)
- Cesar D Lopez
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA.
| | - Matthew J J Anderson
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Colla C, Yang W, Mainor AJ, Meara E, Ouayogode MH, Lewis VA, Shortell S, Fisher E. Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries. Health Serv Res 2020; 55 Suppl 3:1085-1097. [PMID: 33104254 PMCID: PMC7720705 DOI: 10.1111/1475-6773.13580] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. DATA SOURCES Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. STUDY DESIGN Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. DATA COLLECTION/EXTRACTION METHODS 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). PRINCIPAL FINDINGS Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). CONCLUSIONS Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.
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Affiliation(s)
- Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Wendy Yang
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Alexander J. Mainor
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Ellen Meara
- Department of Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusettsUSA
| | - Marietou H. Ouayogode
- Department of Population Health SciencesUniversity of Wisconsin MadisonMadisonWisconsinUSA
| | - Valerie A. Lewis
- Department of Health Policy and ManagementGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Elliott Fisher
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
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Zeldenrust F, Lidstone S, Wu S, Okun MS, Cubillos F, Beck J, Davis T, Lyons K, Nelson E, Rafferty M, Schmidt P, Dai Y, Marras C. Variations in hospitalization rates across Parkinson's Foundation Centers of Excellence. Parkinsonism Relat Disord 2020; 81:123-128. [PMID: 33120073 DOI: 10.1016/j.parkreldis.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients with Parkinson's disease (PD) are at increased risk for hospitalization and often experience worsening of PD when hospitalized. It is therefore important to identify strategies to prevent hospitalization. METHODS Hospital encounter rates in different Parkinson's Foundation Centers of Excellence in United States, Canada, Israel and the Netherlands were analyzed as part of the Parkinson Foundation Parkinson's Outcomes Project (PF-POP). Multivariate logistic regression was used to estimate the odds ratio for hospitalization, adjusted for risk factors. RESULTS Baseline age, disease duration, other relative than spouse/partner as care giver, cancer, arthritis, other comorbidities, falls, use of levodopa, use of dopamine agonist, use of COMT inhibitor, occupational therapy before the baseline visit, PDQ-39, MSCI total score and time between visits were significantly associated with the risk of hospital encounters. After adjustment for these factors, two centers had significantly lower odds for hospitalization admission and ER visit (minimum OR 0.3) and four centers had significantly higher odds (maximum OR 1.5) than the average center. Four centers had significantly lower hazard ratios for time to re-hospitalization compared to the average center. Reducing hospital admission rates in those centers with higher than average rates would reduce overall hospitalizations by 11%. Applied to PD patients over 65 nationwide this represents a potential for cost savings of greater than $1 billion over 48 months. CONCLUSION Encounter rates vary even across expert centers and suggest that practices carried out in some centers may reduce the risk of hospitalization. Further research will be necessary to identify these practices and implement them more widely to improve care for people with PD.
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Affiliation(s)
| | - Sarah Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Samuel Wu
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | | | | | | | - Kelly Lyons
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Eugene Nelson
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Miriam Rafferty
- Shirley Ryan Ability Lab, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Peter Schmidt
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Connie Marras
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
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Shah SS, Tennakoon L, O'Beirne E, Staudenmayer KL, Kothary N. The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development. J Am Coll Radiol 2020; 18:53-59. [PMID: 32918863 DOI: 10.1016/j.jacr.2020.07.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost. METHODS The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, 10th revision, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates. RESULTS Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 versus 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme versus 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% versus 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 versus $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group. CONCLUSIONS Approximately 1 in 10 US inpatients are treated by IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.
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Affiliation(s)
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
| | | | - Kristan L Staudenmayer
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Nishita Kothary
- Department of Radiology, Stanford School of Medicine, Stanford, California.
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An event study of data breaches and hospital IT spending. HEALTH POLICY AND TECHNOLOGY 2020. [DOI: 10.1016/j.hlpt.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lopez CD, Boddapati V, Neuwirth AL, Shah RP, Cooper HJ, Geller JA. Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty. Arthroplast Today 2020; 6:437-444. [PMID: 32613050 PMCID: PMC7320234 DOI: 10.1016/j.artd.2020.04.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Over 1 million total joint arthroplasties (TJAs) are performed every year in the United States, creating Medicare cost concerns for policy makers. The purpose of this study is to evaluate recent trends in Medicare utilization and reimbursements to hospitals/surgeons for TJAs between 2012 and 2017. METHODS We tracked annual Medicare claims and payments to TJA surgeons using publicly available Medicare databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization (per 10,000 Medicare beneficiaries), and reimbursement rates and to examine associations between county-specific variables and TJA utilization and reimbursements. RESULTS Between 2012 and 2017, there was an 18.9% increase in annual primary TJA volume (357,500 cases in 2012 to 425,028 cases in 2017) and a 2.0% increase in annual primary TJA per capita utilization (73.4 cases per 10,000 Medicare beneficiaries in 2012 to 74.8 in 2017). The Midwest and the South had higher utilization rates compared with the Northeast and West (P < .001). Utilization rates for primary TJA procedures also had a significant negative association with the poverty rate (P < .001). Medicare Part B payments to surgeons fell by 7.5%, equivalent to a 14.9% inflation-adjusted decline, whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively, during the study period. CONCLUSIONS Despite increasing TJA volume and utilization, surgeon reimbursements have continued to decline, whereas hospital payments and hospital charges have increased significantly more than surgeon charges. Cost containment efforts will need to address other expenditures such as hospital costs and implant costs to better align financial risks and incentives for TJA surgeons.
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Affiliation(s)
- Cesar D. Lopez
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander L. Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshan P. Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - H. John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey A. Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Einav L, Finkelstein A, Ji Y, Mahoney N. Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform. Proc Natl Acad Sci U S A 2020; 117:18939-18947. [PMID: 32719129 PMCID: PMC7431052 DOI: 10.1073/pnas.2004759117] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Changes in the way health insurers pay healthcare providers may not only directly affect the insurer's patients but may also affect patients covered by other insurers. We provide evidence of such spillovers in the context of a nationwide Medicare bundled payment reform that was implemented in some areas of the country but not in others, via random assignment. We estimate that the payment reform-which targeted traditional Medicare patients-had effects of similar magnitude on the healthcare experience of nontargeted, privately insured Medicare Advantage patients. We discuss the implications of these findings for estimates of the impact of healthcare payment reforms and more generally for the design of healthcare policy.
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Affiliation(s)
- Liran Einav
- Department of Economics, Stanford University, Stanford, CA 94305
- National Bureau of Economic Research, Cambridge, MA 02138
| | - Amy Finkelstein
- National Bureau of Economic Research, Cambridge, MA 02138;
- Department of Economics, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Yunan Ji
- Graduate School of Arts and Sciences, Harvard University, Cambridge, MA 02138
| | - Neale Mahoney
- Department of Economics, Stanford University, Stanford, CA 94305
- National Bureau of Economic Research, Cambridge, MA 02138
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Weeks WB, Weinstein JN. Per Capita Medicare Inflation in the Last Decade: Unit Cost Increases Offset by Reduced Utilization. J Gen Intern Med 2020; 35:1894-1896. [PMID: 31713045 PMCID: PMC7280377 DOI: 10.1007/s11606-019-05553-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 10/31/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - James N Weinstein
- Microsoft Healthcare NExT, Redmond, WA, USA.,Tuck Business School, Hanover, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Kellogg School of Business, Evanston, IL, USA
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The Impact of Internet Medical Information Overflow on Residents' Medical Expenditure Based on China's Observations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103539. [PMID: 32438570 PMCID: PMC7277770 DOI: 10.3390/ijerph17103539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/10/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022]
Abstract
Background: The rapid rise of medical expenditure is a common problem in the field of public health around the world, but the challenges for the Chinese government are even greater. How to control the rapid rise in medical expenditure and reduce individuals' economic burden when receiving medical treatment has become one of the core issues that the Chinese government urgently needs to solve. The aim of this study was to evaluate the impact of Internet use on individuals' medical expenditure and further discuss the potential impact mechanism. Methods: The data used in this study were from the 2018 China Family Panel Studies (CFPS) conducted by Peking University. The Heckman sample selection model was used to analyse the impact of Internet use on individuals' medical expenditure. Results: Internet use reduced the medical expenditure of individuals by 6.19%; high frequency Internet use reduced the medical expenditure of individuals by 15.1%, while low frequency Internet use had no impact. In addition, Internet use had different impacts on individuals' medical expenditure at different levels of hospitals. Specifically, Internet use reduced the medical expenditure of individuals who received medical treatment at general hospitals by 9.63%, and high frequency Internet use reduced the medical expenditure of individuals by 22.2%. However, Internet use had no impact on the medical expenditure of individuals who received medical treatment at primary hospitals. Conclusions: Findings from this study underscore the importance of Internet use as an important role in reducing individuals' medical expenditure. The use of the Internet can significantly reduce the level of individuals' medical expenditure, and high frequency Internet use has a greater effect. However, Internet use has different impacts on individuals' medical expenditure among different levels of hospitals. The reduction effect of Internet use on individuals' medical expenditure is mainly concentrated in general hospitals but has no effect in primary hospitals.
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Kanter GP, Nabet B, Matone M, Rubin DM. Association of State Medicaid Expansion With Hospital Community Benefit Spending. JAMA Netw Open 2020; 3:e205529. [PMID: 32469411 PMCID: PMC7260619 DOI: 10.1001/jamanetworkopen.2020.5529] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. OBJECTIVE To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. DESIGN, SETTING, AND PARTICIPANTS This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. EXPOSURES State Medicaid expansion between 2011 and 2017. MAIN OUTCOMES AND MEASURES Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. RESULTS Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). CONCLUSIONS AND RELEVANCE In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.
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Affiliation(s)
- Genevieve P. Kanter
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bardia Nabet
- Manatt, Phelps, and Phillips, LLP, Washington, DC
| | - Meredith Matone
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - David M. Rubin
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia
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Marrache M, Harris AB, Puvanesarajah V, Raad M, Hassanzadeh H, Srikumaran U, Ficke JR, Levy JF, Jain A. Hospital Payments Increase as Payments to Surgeons Decrease for Common Inpatient Orthopaedic Procedures. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00026. [PMID: 32377615 PMCID: PMC7188271 DOI: 10.5435/jaaosglobal-d-20-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures. Methods Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbar-instrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05). Results Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by -2.2%/year for PSF, -1.5%/year for TKA, -1.1%/year for THA, and -0.4%/year for ACDF (all, P < 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (-4.6%), PSF (-3.1%), TKA (-2.1%), and THA (-1.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P < 0.001). Conclusions From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these procedures. Payments to orthopaedic surgeons for these procedures decreased markedly during the same period.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Joseph F Levy
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
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Cheng TM. Bending the Cost Growth Curve and Expanding Coverage: Lessons from Germany's All-Payer System A Tribute to Uwe Reinhardt. Milbank Q 2020; 98:279-296. [PMID: 32108373 DOI: 10.1111/1468-0009.12453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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All-payer Spending on Common Hospital-based Services in California. Med Care 2020; 58:534-540. [PMID: 32044867 DOI: 10.1097/mlr.0000000000001303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital-based care accounts for one third of US health spending or over $1 trillion annually, yet a detailed all-payer assessment of what services contribute to this spending is not available. STUDY DESIGN Cross-sectional and longitudinal evaluation of hospital financial statements from acute-care general hospitals in California between fiscal years 2007 and 2016. The amounts spent on 41 different revenue centers were included. The primary outcome was state-level and hospital-level spending for each revenue center including decomposing growth trends into changes in volume and prices. RESULTS The analysis included 2941 annual financial statements from 331 hospitals. Between 2007 and 2016, total spending across all centers increased 66.6% from $43.7B to $72.9B. Five centers-surgery and recovery, drugs sold to patients, acute medical/surgical floor, the clinical laboratory, and emergency services-accounted for over 50% of total spending in 2016. Overall spending growths ranged from 1.1%/y (acute pediatrics) to 17.9%/y (observation). Other revenue centers with large increases in spending included emergency services (164.7%), clinics (on-site 114.5%, satellite 129.7%), anesthesia (119.6%), echocardiography (114.4%), and computed tomography (100.8%). Most services had volume growths within ±2%/y, although there were exceptions (eg, observation hours increased 10.0%/y). Prices grew fastest for echocardiograms (10.5%/y), cardiac catheterization (9.7%/y), therapeutic radiology (8.0%/y), and emergency visits (7.5%/y). In general, median prices for services in 2016 were larger than Medicare allowed amounts. CONCLUSIONS Overall hospital-based spending increased 66.6% between 2007 and 2016 in California, but there was wide variation in spending growth across revenue centers. Understanding this variation-including the relative contributions of volumes and prices-can guide efforts to curb excessive health care spending and optimize resource dedication to current and future patient care needs.
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Crowley R, Daniel H, Cooney TG, Engel LS. Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care. Ann Intern Med 2020; 172:S7-S32. [PMID: 31958805 DOI: 10.7326/m19-2415] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Ryan Crowley
- American College of Physicians, Washington, DC (R.C., H.D.)
| | - Hilary Daniel
- American College of Physicians, Washington, DC (R.C., H.D.)
| | - Thomas G Cooney
- Oregon Health & Science University and Portland Veterans Affairs Medical Center, Portland, Oregon (T.G.C.)
| | - Lee S Engel
- Louisiana State University Health Sciences Center, New Orleans, Louisiana (L.S.E.)
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Chiu RG, Murphy BE, Rosenberg DM, Zhu AQ, Mehta AI. Association of for-profit hospital ownership status with intracranial hemorrhage outcomes and cost of care. J Neurosurg 2019; 133:1939-1947. [PMID: 31783363 DOI: 10.3171/2019.9.jns191847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Much of the current discourse surrounding healthcare reform in the United States revolves around the role of the profit motive in medical care. However, there currently exists a paucity of literature evaluating the effect of for-profit hospital ownership status on neurological and neurosurgical care. The purpose of this study was to compare inpatient mortality, operation rates, length of stay, and hospital charges between private nonprofit and for-profit hospitals in the treatment of intracranial hemorrhage. METHODS This retrospective cohort study utilized data from the National Inpatient Sample (NIS) database. Primary outcomes, including all-cause inpatient mortality, operative status, patient disposition, hospital length of stay, total hospital charges, and per-day hospital charges, were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographics, comorbidities, and interhospital differences via propensity score matching. Subgroup analyses by hemorrhage type were then performed, using the same methodology. RESULTS Of 155,977 unique hospital discharges included in this study, 133,518 originated from private nonprofit hospitals while the remaining 22,459 were from for-profit hospitals. After propensity score matching, mortality rates were higher in for-profit centers, at 14.50%, compared with 13.31% at nonprofit hospitals (RR 1.09, 95% CI 1.00-1.18; p = 0.040). Surgical operation rates were also similar (25.38% vs 24.42%; RR 0.96, 95% CI 0.91-1.02; p = 0.181). Of note, nonprofit hospitals appeared to be more intensive, with intracranial pressure monitor placement occurring in 2.13% of patients compared with 1.47% in for-profit centers (RR 0.69, 95% CI 0.54-0.88; p < 0.001). Discharge disposition was also similar, except for higher rates of absconding at for-profit hospitals (RR 1.59, 95% CI 1.12-2.27; p = 0.018). Length of stay was greater among for-profit hospitals (mean ± SD: 7.46 ± 11.91 vs 6.50 ± 8.74 days, p < 0.001), as were total hospital charges ($141,141.40 ± $218,364.40 vs $84,863.54 ± $136,874.71 [USD], p < 0.001). These findings remained similar even after segregating patients by subgroup analysis by hemorrhage type. CONCLUSIONS For-profit hospitals are associated with higher inpatient mortality, lengths of stay, and hospital charges compared with their nonprofit counterparts.
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Agarwal SK, Soliman AM, Bond JC, Epstein AJ. National Patterns of Emergency Department Use for Women with Endometriosis, 2006-2015. J Womens Health (Larchmt) 2019; 29:420-426. [PMID: 31718410 DOI: 10.1089/jwh.2019.7879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction: Endometriosis is a burdensome chronic condition for which conservative management is often recommended when indicated. Nonetheless, some women seek care for endometriosis in the emergency department (ED). We evaluated trends in ED visits for endometriosis from 2006 to 2015. Materials and Methods: Nationally representative estimates of ED visits for endometriosis by women aged 18-49 were extracted from the Health Care Utilization Project Nationwide Emergency Department Sample into three cohorts by calendar years 2006-2007, 2010-2011, and 2014-Q3 2015. Visits with a principal diagnosis code of endometriosis (International Classification of Disease, 9th Edition, Clinical Modification, code 617.x) were included. Patient and hospital characteristics were compared across cohorts using analysis of variance. Trends in the proportion of ED visits ending in inpatient admission and in mean charges (2015 USD) were assessed using generalized linear models controlling for patient and hospital characteristics. Results: The annual number of ED visits nationally was stable at ∼15,000 visits per year during 2006-2015. From 2006-2007 to 2014-2015, the composition of ED visits shifted away from private pay (42.0% vs. 35.3%) and uninsured (23.6% vs. 16.6%) to Medicaid (26.7% vs. 40.1%) and became more concentrated in metro-teaching hospitals (33.9% vs. 51.9%) (p < 0.001 for all). Inpatient admission rates declined from 20.1% to 9.2% (p < 0.001). Mean ED charges increased from $2458 to $4953 (p < 0.001). Conclusion: During 2006-2015, the number of ED visits for endometriosis remained stable, the inpatient admission/transfer rate declined by half, and mean charges per visit doubled.
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Affiliation(s)
- Sanjay K Agarwal
- Center for Endometriosis Research and Treatment, University of California San Diego, La Jolla, California
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Affiliation(s)
- Karen E Joynt Maddox
- Washington University School of Medicine, St Louis, Missouri
- Institute for Public Health at Washington University, St Louis, Missouri
- Associate Editor
| | - Mark B McClellan
- Duke University School of Medicine, Durham, North Carolina
- Duke Margolis Center for Health Policy, Durham, North Carolina
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Gourin CG, Vosler PS, Mandal R, Pitman KT, Fakhry C, Eisele DW, Frick KD, Austin JM. Association Between Hospital Market Concentration and Costs of Laryngectomy. JAMA Otolaryngol Head Neck Surg 2019; 145:939-947. [PMID: 31465102 PMCID: PMC6716289 DOI: 10.1001/jamaoto.2019.2303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/28/2019] [Indexed: 11/14/2022]
Abstract
IMPORTANCE High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined. OBJECTIVE To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy. DESIGN, SETTING, AND PARTICIPANTS The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018. MAIN OUTCOMES AND MEASURES Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy. RESULTS Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%). CONCLUSIONS AND RELEVANCE Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.
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Affiliation(s)
- Christine G. Gourin
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Peter S. Vosler
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rajarsi Mandal
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Karen T. Pitman
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David W. Eisele
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kevin D. Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Johns Hopkins Carey Business School, Baltimore, Maryland
| | - J. Matthew Austin
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Hoffer EP. America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors. Am J Med 2019; 132:907-911. [PMID: 30928345 DOI: 10.1016/j.amjmed.2019.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 02/01/2023]
Abstract
Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.
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Affiliation(s)
- Edward P Hoffer
- Laboratory of Computer Science, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, MA.
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Affiliation(s)
- Aaron Glickman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah S P DiMagno
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
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