Price transparency implementation: Accessibility of hospital chargemasters and variation in hospital pricing after CMS mandate.

BACKGROUND: National regulations have increasingly focused on transparency in hospital billing and pricing practices. A January 2019 federal mandate required hospitals to publicize lists of billable procedures and items known as chargemasters. METHODS: We identified the 500 top self-pay/uninsured revenue grossing hospitals nationally and searched each hospital's website for a chargemaster. Corresponding items were matched across chargemasters. Intrahospital and interhospital price variation were calculated. To investigate variation in item naming, a name variant and fuzzy matching search was conducted for fifteen common chargemaster items. RESULTS: Of 500 hospitals in this study, 69 (13.8%) had chargemasters that were inaccessible and 30 (6.0%) had chargemasters that did not meet mandated requirements. Among the remaining 431 hospitals, the mean interhospital and intrahospital variation in pricing for identical items was 18% (SD 28%) and 28% (SD 29%), respectively. 388 hospitals listed multiple prices for the same item, with a mean of 687.3 duplicated items (SD 1157.7). Among fifteen common chargemaster items, each item was associated with an average of 275 (SD 213) unique name variants. Interhospital price variation of these items ranged from 53% (transthoracic echocardiogram) to 243% (furosemide 40 mg). CONCLUSIONS: Many chargemasters have barriers to access, and item naming is inconsistent across chargemasters. There is significant interhospital price variation for similar items. IMPLICATIONS: Chargemasters are uninterpretable for the purpose of patient price comparison in their current form. Further regulatory efforts are necessary to increase price transparency and enhance the ability of patients to compare hospital prices.

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center.

BACKGROUND: Prior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid. METHODS: Charges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc. RESULTS: During 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%. CONCLUSIONS: Self-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

The ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care.

OBJECTIVE: To estimate the effect of the first full year of the ACA Medicaid expansion on hospital provision of uncompensated care, with special attention paid to hospitals that treat a disproportionate share of low-income patients. DATA SOURCES: Data from a balanced panel of short-term, general, nonfederal, Medicare-certified hospitals were obtained from Medicare cost reports from 2011 to 2014. STUDY DESIGN/STUDY SETTING: A series of difference-in-differences analyses were performed using hospitals in nonexpansion states as the control group. The dependent variable is hospital provision of uncompensated care. DATA COLLECTION/EXTRACTION METHODS: The data were downloaded from the National Bureau of Economic Research website. PRINCIPAL FINDINGS: The Medicaid expansion significantly reduced hospital provision of uncompensated care in 2014. In particular, within expansion states, DSH hospitals saw reductions beyond those experienced by non-DSH hospitals. CONCLUSIONS: Evidence from this study indicates that the Medicaid expansion served to widen an already broad gap in provision of uncompensated care between hospitals in expansion and nonexpansion states. In addition, within expansion states, variation in uncompensated care between hospitals that treat a disproportionate share of low-income patients and those that do not was reduced, with the former experiencing significantly larger reductions. Lawmakers considering expanding Medicaid and those deciding appropriate levels of DSH payments should consider these findings.

Can Disproportionality Analysis of Post-marketing Case Reports be Used for Comparison of Drug Safety Profiles?

Clinical trials usually do not have the power to detect rare adverse drug reactions. Spontaneous adverse reaction reports as for example available in post-marketing safety databases such as the FDA Adverse Event Reporting System (FAERS) are therefore a valuable source of information to detect new safety signals early. To screen such large data-volumes for safety signals, data-mining algorithms based on the concept of disproportionality have been developed. Because disproportionality analysis is based on spontaneous reports submitted for a large number of drugs and adverse event types, one might consider using these data to compare safety profiles across drugs. In fact, recent publications have promoted this practice, claiming to provide guidance on treatment decisions to healthcare decision makers. In this article we investigate the validity of this approach. We argue that disproportionality cannot be used for comparative drug safety analysis beyond basic hypothesis generation because measures of disproportionality are: (1) missing the incidence denominators, (2) subject to severe reporting bias, and (3) not adjusted for confounding. Hypotheses generated by disproportionality analyses must be investigated by more robust methods before they can be allowed to influence clinical decisions.

Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals.

Purpose: This policy brief provides data assessing effects of Medicaid Disproportionate Share Hospital (DSH) payment on rural hospitals in 47 states. While the allocation of DSH funds to the state is determined by federal legislation utilizing a formula developed by the Centers for Medicare & Medicaid Services (CMS), each state determines distribution to hospitals using an approved State Plan Amendment (SPA) that meets minimum federal requirements. Our findings suggest that distribution to rural hospitals, and critical access hospitals (CAHs) in particular, varies considerably across states. Data presented in this document helps ground any changes to either federal requirements or to SPAs by showing the impact of DSH payment from the most recent data available. Key Findings: (1) Medicaid DSH payment methodology and distribution to hospitals varies considerably across states. (2) The percentage of rural hospitals in a state receiving any Medicaid DSH payment ranged from 0 percent to 100 percent. (3) For rural hospitals receiving Medicaid DSH payments, the impact on total patient revenue ranged from less than 0.5 percent to 8.8 percent.

Medicare, swing beds, and critical access hospitals.

Critical Access Hospitals (CAHs) receive cost-based reimbursement from Medicare for inpatient care, including post-acute skilled care provided in swing beds (skilled swing days). Because the reimbursement formula treats swing bed and acute days equally, there is concern that CAH skilled swing days are "overreimbursed" as compared with skilled days provided in other settings. The reimbursement formula is complex; thus, empirical estimates are needed to identify the marginal cost per day to the hospital and the implied Medicare expenditure per day, accounting for fixed cost transfers between services. Using Medicare cost report data, we find that Medicare paid, on average, $581 for the routine portion of a CAH skilled swing day in 2009--more than the estimated marginal cost of $262, but less than the 2009 average per diem of $1,302. Estimates varied widely across the 1,300 CAHs; therefore, payment policy changes would likely have a broad range of effects.

Higher readmissions at safety-net hospitals and potential policy solutions.

The Hospital Readmissions Reduction Program (HRRP), established by the Affordable Care Act, ties a hospital's payments to its readmission rates--with penalties for hospitals that exceed a national benchmark--to encourage hospitals to reduce avoidable readmissions. This new Commonwealth Fund analysis uses publicly reported 30-day hos­pital readmission rate data to examine whether safety-net hospitals are more likely to have higher readmission rates, compared with other hospitals. Results of this analysis find that safety-net hospitals are 30 percent more likely to have 30-day hospital readmission rates above the national average, compared with non-safety-net hospitals, and will therefore be disproportionately impacted by the HRRP. Policy solutions to help safety-net hospi­tals reduce their readmission rates include targeting quality improvement initiatives for safety-net hospitals; ensuring that broader delivery system improvements include safety-net hospitals and care delivery systems; and enhancing bundled payment rates to account for socioeconomic risk factors.

Indirect medical education and disproportionate share adjustments to Medicare inpatient payment rates.

The indirect medical education (IME) and disproportionate share hospital (DSH) adjustments to Medicare's prospective payment rates for inpatient services are generally intended to compensate hospitals for patient care costs related to teaching activities and care of low income populations. These adjustments were originally established based on the statistical relationships between IME and DSH and hospital costs. Due to a variety of policy considerations, the legislated levels of these adjustments may have deviated over time from these "empirically justified levels," or simply, "empirical levels." In this paper, we estimate the empirical levels of IME and DSH using 2006 hospital data and 2009 Medicare final payment rules. Our analyses suggest that the empirical level for IME would be much smaller than under current law-about one-third to one-half. Our analyses also support the DSH adjustment prescribed by the Affordable Care Act of 2010 (ACA)--about one-quarter of the pre-ACA level. For IME, the estimates imply an increase in costs of 1.88% for each 10% increase in teaching intensity. For DSH, the estimates imply that costs would rise by 0.52% for each 10% increase in the low-income patient share for large urban hospitals.

The impact of the Balanced Budget Act on the utilization and financial condition of children's services in California hospitals.

The objective of this study was to evaluate the utilization and financial performance of children's services after the Balanced Budget Act of 1997. The author analyzed these performance factors by hospital ownership, HMO penetration, and disproportionate share hospitals. Using data from California hospitals and conducting an analysis from 1997 to 1999, the author found that public hospitals were able to increase their profits from pediatric and neonatal intensive care services. The study also revealed that DSH hospitals located in high HMO penetration markets reduced their operating losses in nursery and pediatric services.

Reforming the Medicaid disproportionate share hospital program.

Since 1991, three Federal laws have sought to reform the Medicaid disproportionate share hospital (DSH) program, which is designed to help safety net hospitals. This article provides findings from a 40-State survey about Medicaid DSH and supplemental payment programs in 1997. Results indicate that the overall size of the DSH program did not grow from 1993 to 1997, but the composition of DSH revenues and expenditures changed substantially: A much higher share of the DSH funds were being paid to local hospitals and relatively less was being retained by the States. The study also revealed that large differences in States' use of DSH still persist.