Interhospital competition and hospital charges and costs for patients undergoing cranial neurosurgery

The Gap Between the Actual Cost and Tariffs of Global Surgical Procedures: A Retrospective Cross-sectional Study in Qazvin Province, Iran

BACKGROUND

Iran's healthcare system has a significant discrepancy between the national tariff and the cost of global surgical procedures (GSPs). This study aimed to compare the actual costs of GSPs with national tariffs in Iran's public hospitals.

METHODS

This retrospective cross-sectional study was conducted in 2017. Using the census method, 6126 GSPs performed in three public hospitals were investigated in this study. Additionally, national tariffs from the Supreme Council of Health Insurance were obtained. The tariff-cost gap was the discrepancy between a GSP's actual costs and tariff. Multiple linear regression analysis determined factors affecting the tariff-cost gap.

RESULTS

The average actual cost of GSPs was 637 USD, while the average tariff was 495 USD. The reimbursement covered only 78% of the costs. The gap was higher in older (B=1.05, 95% CI: 0.76-1.35, P<0.001), females (B=26.7, 95% CI: 15.5-37.9, P<0.001), patients with a longer stay (B=81.2, 95% CI: 77.5-84.8, P<0.001), and procedures performed by full-time surgeons (B=67.3, 95% CI: 56.9-77.5, P<0.001). Furthermore, neurosurgery had the highest effect on forecasting the gap between actual costs and tariffs among surgical specialties (B=346.9, 95% CI: 214.3-479.5, P<0.001).

CONCLUSION

Public hospitals suffer from large financial losses due to the national tariff for many GSPs not covering their actual costs. It is suggested that tariffs be increased for certain customer segments that can bear higher costs and global tariffs be adjusted to match actual service delivery costs.

Consolidation of the perinatal care system and workload of obstetricians: an ecological study in Japan

Objectives

We examined the relationship between consolidation of delivery and the workload of obstetricians working at perinatal centers.

Methods

We conducted a descriptive analysis using perinatal care areas classified into three types (metropolitan, provincial, and rural). We calculated the Herfindahl-Hirschman Index (HHI) as an index of consolidation and the proportion of the deliveries at clinics as an indicator of the low-risk deliveries and the deliveries per center obstetrician as an indicator of obstetricians' workload. We used >150 deliveries yearly as an excess indicator. The correlation between the HHI and obstetricians' workload and the proportion of deliveries at clinics was examined using the Pearson correlation coefficient.

Results

The proportion of areas with  >150 deliveries yearly was higher in the consolidated areas. In provincial areas, obstetricians' workload was positively correlated with the HHI and was negatively correlated with the proportion of deliveries at clinics.

Conclusions

The obstetricians' workload may be increasing where more consolidation occurs. In provincial areas, the center obstetrician's workload could be reduced not only by consolidation but also by sharing the role of handling low-risk deliveries with clinics and hospitals with obstetric units other than perinatal centers.

Brain tumor craniotomy outcomes for dual-eligible medicare and medicaid patients: a 10-year nationwide analysis

INTRODUCTION

Dual-eligible (DE) patients, simultaneous Medicare and Medicaid beneficiaries, have been shown to have poorer clinical outcomes while incurring higher resource utilization. However, neurosurgical oncology outcomes for DE patients are poorly characterized. Accordingly, we examined the impact of DE status on perioperative outcomes following glioma, meningioma, or metastasis resection.

METHODS

We identified all admissions undergoing a craniotomy for glioma, meningioma, or metastasis resection in the National Inpatient Sample from 2002 to 2011. Assessed outcomes included inpatient mortality, complications, discharge disposition, length of stay (LOS), and hospital costs. Multivariable regression adjusting for 13 patient, severity, and hospital characteristics assessed the association between DE status and outcomes, relative to four reference insurance groups (Medicare-only, Medicaid-only, private insurance, self-pay).

RESULTS

Of 195,725 total admissions analyzed, 3.0% were dual-eligible beneficiaries (n = 5933). DEs were younger than Medicare admissions (P < 0.001) but older than Medicaid, private, and self-pay admissions (P < 0.001). Relative to other insurance groups, DEs also exhibited higher severity of illness, risk of mortality, and Charlson Comorbidity Index scores as well as treatment at low-volume hospitals (all P < 0.001). DEs had lower mortality than self-pay admissions (odds ratio [OR] 0.47, P = 0.017). Compared to Medicare, Medicaid, private, and self-pay admissions, DEs had lower rates of discharge disposition (OR 0.53, 0.50, 0.34, and 0.27, respectively, all P < 0.001). DEs also had higher complications (OR 1.23 and 1.20, respectively, both P < 0.05) and LOS (β = 1.06 and 1.13, respectively, both P < 0.01) than Medicare and private insurance beneficiaries. Differences in discharge disposition remained significant for all three tumor subtypes, but only glioma DE admissions continued to exhibit higher complications and LOS.

CONCLUSIONS

DEs undergoing definitive craniotomy for brain tumor had higher rates of unfavorable discharge disposition compared to all other insurance groups and, especially for glioma surgery, had higher inpatient complication rates and LOS. Practice and policy reforms to improve outcomes for this vulnerable clinical population are warranted.

Heterogeneous effects of hospital competition on inpatient expenses: an empirical analysis of diseases grouping basing on conditions' complexity and urgency

Background

Multiple pro-competition policies were implemented during the new round of healthcare reform in China. Differences in conditions’ complexity and urgency across diseases associating with various degrees of information asymmetry and choice autonomy in the process of care provision, would lead to heterogeneous effects of competition on healthcare expenses. However, there are limited studies to explore it. This study aims to examine the heterogeneous effects of hospital competition on inpatient expenses basing on disease grouping according to conditions’ complexity and urgency.

Methods

Collecting information from discharge data of inpatients and hospital administrative data of Sichuan province in China, we selected representative diseases. K-means clustering was used to group the selected diseases and Herfindahl-Hirschman Index (HHI) was calculated based on the predicted patient flow to measure the hospital competition. The log-linear multivariate regression model was used to examine the heterogeneous effects of hospital competition on inpatient expenses.

Results

We selected 19 representative diseases with significant burdens (more than 1.1 million hospitalizations). The selected diseases were divided into three groups, including diseases with highly complex conditions, diseases with urgent conditions, and diseases with less complex and less urgent conditions. For diseases with highly complex conditions and diseases with urgent conditions, the estimated coefficients of HHI are mixed in the direction and statistical significance in the identical regression model at the 5% level. For diseases with less complex and less urgent conditions, the coefficients of HHI are all positive, and almost all of them significant at the 5% level.

Conclusions

We found heterogeneous effects of hospital competition on inpatient expenses across disease groups: hospital competition does not play an ideal role in reducing inpatient expenses for diseases with highly complex conditions and diseases with urgent conditions, but it has a significant effect in reducing inpatient expenses of diseases with less complex and less urgent conditions. Our study offers implications that the differences in condition’s complexity and urgency among diseases would lead to different impacts of hospital competition, which would be given full consideration when designing the pro-competition policy in the healthcare delivery system to achieve the desired goal.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07331-1.

The Impact of Interhospital Competition on Treatment Strategy and Outcomes for Unruptured Intracranial Aneurysms

BACKGROUND

Interhospital competition has been shown to affect surgical outcomes and expenditures. However, interhospital competition's impact on neurosurgery is poorly characterized.

OBJECTIVE

To assess how interhospital competition is associated with treatment strategy and outcomes for unruptured intracranial aneurysms (UIAs).

METHODS

We identified all elective UIA admissions in the National Inpatient Sample from 2002 to 2011. Competitive intensity of each hospital market was quantified using the validated Herfindahl-Hirschman Index (HHI), with lower values denoting higher competition. We then obtained nationwide HHI values for 2012 to 2016 from the Health Care Cost Project. Outcomes included treatment modality (clipping, coiling, or nonoperative management), inpatient mortality, disposition, complications, length of stay (LOS), and costs. Multivariate regression assessed the association between HHI and outcomes, controlling for patient demographics, severity metrics, hospital characteristics, and treatment.

RESULTS

We studied 157 979 elective UIA admissions at 1435 hospitals from 2002 to 2011, with an increase in coiling admissions (13.4% to 33.7%) and decrease in clipping admissions (30.9% to 17.6%). Mean hospital HHI was 0.11 (range = 0.001-0.97). Competition decreased for 61.8% of hospitals from 2002 to 2011 and 68.1% of metropolitan localities from 2012 to 2016. Admissions in more competitive hospital markets exhibited increased odds of undergoing surgery (odds ratio [OR] = 1.37, P < .001), with preference toward coiling over clipping (OR = 1.27, P < .001). HHI was not associated with mortality, disposition, or LOS. However, increased interhospital competition was associated with more complications (OR = 1.09, P = .001) and greater hospital costs (β-coefficient = 1.06, P < .001).

CONCLUSION

For UIA patients, admission to hospitals in more competitive geographies was associated with increased rates of surgical intervention, coiling utilization, complications, and hospitalization costs.