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1.
N Engl J Med ; 385(7): 618-627, 2021 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-34379923

RESUMO

BACKGROUND: The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments. METHODS: We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix. RESULTS: A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix. CONCLUSIONS: The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.).


Assuntos
Economia Hospitalar , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Melhoria de Qualidade/economia , Mecanismo de Reembolso , Idoso , Idoso de 80 Anos ou mais , Grupos Diagnósticos Relacionados , Cuidado Periódico , Feminino , Insuficiência Cardíaca/terapia , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Análise de Regressão , Estados Unidos
8.
Health Aff (Millwood) ; 40(1): 82-90, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33400570

RESUMO

States' decisions to expand Medicaid may have important implications for their hospitals' financial ability to weather the coronavirus disease 2019 (COVID-19) pandemic. This study estimated the effects of the Affordable Care Act (ACA) Medicaid expansion on hospital finances in 2017 to update earlier findings. The analysis also explored how the ACA Medicaid expansion affects different types of hospitals by size, ownership, rurality, and safety-net status. We found that the early positive financial impact of Medicaid expansion was sustained in fiscal years 2016 and 2017 as hospitals in expansion states continued to experience decreased uncompensated care costs and increased Medicaid revenue and financial margins. The magnitude of these impacts varied by hospital type. As COVID-19 has brought hospitals to a time of great need, findings from this study provide important information on what hospitals in states that have yet to expand Medicaid could gain through expansion and what is at risk should any reversal of Medicaid expansions occur.


Assuntos
COVID-19/epidemiologia , Economia Hospitalar , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , Humanos , Medicaid/economia , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , SARS-CoV-2 , Governo Estadual , Estados Unidos
11.
Med Care ; 59(3): 213-219, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33427797

RESUMO

BACKGROUND: In anticipation of a demand surge for hospital beds attributed to the coronavirus pandemic (COVID-19) many US states have mandated that hospitals postpone elective admissions. OBJECTIVES: To estimate excess demand for hospital beds due to COVID-19, the net financial impact of eliminating elective admissions in order to meet demand, and to explore the scenario when demand remains below capacity. RESEARCH DESIGN: An economic simulation to estimate the net financial impact of halting elective admissions, combining epidemiological reports, the US Census, American Hospital Association Annual Survey, and the National Inpatient Sample. Deterministic sensitivity analyses explored the results while varying assumptions for demand and capacity. SUBJECTS: Inputs regarding disease prevalence and inpatient utilization were representative of the US population. Our base case relied on a hospital admission rate reported by the Center for Disease Control and Prevention of 137.6 per 100,000, with the highest rates in people aged 65 years and older (378.8 per 100,000) and 50-64 years (207.4 per 100,000). On average, elective admissions accounted for 20% of total hospital admissions, and the average rate of unoccupied beds across hospitals was 30%. MEASURES: Net financial impact of halting elective admissions. RESULTS: On average, hospitals COVID-19 demand for hospital bed-days fell well short of hospital capacity, resulting in a substantial financial loss. The net financial impact of a 90-day COVID surge on a hospital was only favorable under a narrow circumstance when capacity was filled by a high proportion of COVID-19 cases among hospitals with low rates of elective admissions. CONCLUSIONS: Hospitals that restricted elective care took on a substantial financial risk, potentially threatening viability. A sustainable public policy should therefore consider support to hospitals that responsibly served their communities through the crisis.


Assuntos
COVID-19/epidemiologia , Economia Hospitalar/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Adulto , Idoso , Ocupação de Leitos/economia , Ocupação de Leitos/estatística & dados numéricos , Feminino , Número de Leitos em Hospital/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Pandemias , SARS-CoV-2 , Estados Unidos/epidemiologia
12.
Am J Emerg Med ; 45: 578-589, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33402309

RESUMO

BACKGROUND: Emergency department (ED) care coordination plays an important role in facilitating care transitions across settings. We studied ED care coordination processes and their perceived effectiveness in Maryland (MD) hospitals, which face strong incentives to reduce hospital-based care through global budgets. METHODS: We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes and perceptions of effectiveness. Interviews were conducted from January through October 2019 across MD hospital-based EDs. Results were reviewed to assign analytic domains and identify emerging themes. Descriptive statistics of ED care coordination staffing and processes were also calculated. RESULTS: A total of 25 in-depth interviews across 18 different EDs were conducted with ED physician leadership (n = 14) and care coordination staff (CCS) (n = 11). Across all EDs, there was significant variation in the hours and types of CCS coverage and the number of initiatives implemented to improve care coordination. Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. The majority of ED physician leaders perceived MD's policy reform as having a mixed impact, with improved care transitions and overall patient care as benefits, but increased physician workloads and worsened ED throughput as negative effects. CONCLUSIONS: EDs have responded to the value-based care incentives of MD's global budgeting program with investments to enhance care coordination staffing and a variety of initiatives targeting specific patient populations. Although the observed care coordination initiatives were broadly perceived to produce positive results, MD's global budgeting policies were also perceived to produce barriers to optimizing ED care. Further research is needed to determine the association of the various strategies to improve ED care coordination with patient outcomes to inform practice leaders and policymakers on the efficacy of the various approaches.


Assuntos
Economia Hospitalar/tendências , Serviço Hospitalar de Emergência/organização & administração , Reforma dos Serviços de Saúde/economia , Avaliação de Processos em Cuidados de Saúde , Humanos , Entrevistas como Assunto , Maryland , Admissão e Escalonamento de Pessoal , Pesquisa Qualitativa
13.
J Shoulder Elbow Surg ; 30(1): 113-119, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32807371

RESUMO

BACKGROUND: Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. METHODS: A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. RESULTS: Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. CONCLUSIONS: Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.


Assuntos
Artroplastia do Ombro , Cirurgiões Ortopédicos/economia , Articulação do Ombro , Artroplastia do Ombro/economia , Artroplastia do Ombro/instrumentação , Artroplastia do Ombro/estatística & dados numéricos , Custos e Análise de Custo , Economia Hospitalar/estatística & dados numéricos , Cuidado Periódico , Custos Hospitalares/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Cirurgiões Ortopédicos/estatística & dados numéricos , Estudos Retrospectivos , Articulação do Ombro/cirurgia , Prótese de Ombro/economia , Estados Unidos/epidemiologia
14.
J Rural Health ; 37(1): 133-141, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33030761

RESUMO

PURPOSE: Amidst the COVID-19 outbreak, the use of intensive care unit telemedicine (tele-ICUs) may be one mechanism to provide patient care, particularly in rural parts of the United States. The purpose of this research was to inform hospital decision makers considering tele-ICUs, policy makers weighing immediate and longer-term funding and reimbursement decisions relative to tele-ICU care, and researchers conducting future work evaluating tele-ICUs. METHODS: We compared hospitals that reported providing teleintensive care to hospitals that reported not providing teleintensive care in the 2018 American Hospital Association Annual Survey (AHAAS). Differences between groups were tested using Pearson's chi-square (categorical variables) and t-tests (continuous variables) using 0.05 as the probability of Type 1 error. The study sample included all US short-term, acute care hospitals that responded to the AHAAS in 2018. Our key variable of interest was whether a hospital reported having any tele-ICU capabilities in the 2018 AHAAS. Other factors evaluated were ownership, region, beds, ICU beds, outpatient visits, emergency department visits, full-time employees, and whether a hospital was rural, a critical access hospital, a major teaching hospital, or part of a health system. FINDINGS: Larger, not-for-profit, nonrural, noncritical access, teaching hospitals that were part of a health system, particularly in the Midwest, were more likely to have tele-ICUs. Over one-third of hospital referral regions (HRRs) had zero hospitals with tele-ICUs, 4 had all hospitals with tele-ICU, and the median percent of hospitals with tele-ICU by HRR, weighted by outpatient visits, was 11.3%. CONCLUSIONS AND IMPLICATIONS: We found wide variation in the prevalence of tele-ICUs across HRRs and states. Future work should continue the evaluation of tele-ICU effectiveness and, if favorable, explore the variation we identified for improved access to teleintensive care.


Assuntos
COVID-19/epidemiologia , Hospitais/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Serviços de Saúde Rural/organização & administração , Telemedicina/organização & administração , Economia Hospitalar , Humanos , Reembolso de Seguro de Saúde , Propriedade , Prevalência , Características de Residência , Serviços de Saúde Rural/economia , SARS-CoV-2 , Telemedicina/economia , Estados Unidos/epidemiologia
15.
Mayo Clin Proc ; 96(1): 174-182, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33168158

RESUMO

New technologies in medicine, even if they are promising medically, are often expensive and logistically difficult to implement at the hospital level. Transcatheter aortic valve replacement (TAVR) is a model technology that is revolutionary in treating aortic stenosis, but has been plagued with significant challenges with financial sustainability. In this article, a margin analysis at the hospital level was performed using literature data. A TAVR industry analysis was performed using Porter's Five Forces framework. The data indicate that TAVR is more expensive than surgical aortic valve replacement, although the cost of TAVR is declining with the use of an optimized minimalist protocol. The overall industry is growing as its clinical indications expand, and it will likely undergo significant reduction of costs when new valves enter the US market. As such, TAVR is a growing industry, with financial sustainability currently dependent on operational efficiency. A concluding list of specific program interventions is provided to help TAVR programs improve operational efficiency and clinical outcomes, as well as help decide whether to create, expand, or redirect funding for TAVR programs. Importantly, the frameworks used to analyze this rapidly evolving technology can be applied to other new technologies to determine financial sustainability.


Assuntos
Economia Hospitalar/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/economia , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/cirurgia , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Estados Unidos
16.
J Plast Reconstr Aesthet Surg ; 74(1): 192-198, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33129699

RESUMO

INTRODUCTION: The advent of wide-awake local anaesthesia has led to a reduced need for main theatre for trauma and elective plastic procedures. This results in significant cost-benefits for the institution. This study aims to show how a dedicated 7 days/ week plastic surgery procedural (PSP) unit, performing both elective and trauma surgeries, can lead to significant cost-benefits for the institution. METHODS: Retrospective review of all cases performed in the PSP unit between 1 September and 31 August 2018. We utilised hospital directory admissions data and the hospital's intranet operating theatre system to calculate hospital days saved. Cost analysis was performed using Saolta financial data. RESULTS: A total of 3058 operations were performed. Of these operations, 2388 cases were elective and 670 were trauma cases. The average waiting time for trauma cases for main operating theatre was 1.4 days, saving a total of 487 hospital days. The total savings associated with hospital bed days were €347,861. The estimated resource savings from performing a procedure in PSP compared with main theatre with regional anaesthesia were €529.00 and €391.00 without regional anaesthesia. The cost saved due to resources was therefore €337,226. The total cost-benefit associated with performing surgeries in PSP including hospital days and resources saved was calculated as €685,087. CONCLUSION: This study shows the benefit of performing elective and trauma operations in minor procedure units such as PSP. PSP results in a more efficient service, reducing waiting times for surgery, shorter hospital stay, reduced operating cost and an overall significant cost saving.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Unidades Hospitalares/economia , Hospitais/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Cirurgia Plástica/economia , Ferimentos e Lesões/cirurgia , Anestesia por Condução/economia , Redução de Custos , Análise Custo-Benefício , Economia Hospitalar , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Unidades Hospitalares/estatística & dados numéricos , Humanos , Irlanda , Tempo de Internação/economia , Salas Cirúrgicas/economia , Recursos Humanos em Hospital/economia , Estudos Prospectivos , Estudos Retrospectivos , Cirurgia Plástica/estatística & dados numéricos , Fatores de Tempo
17.
Ann Intern Med ; 174(1): 86-92, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33045180

RESUMO

The Hospital Readmissions Reduction Program (HRRP) has penalized hospitals with higher 30-day readmission rates more than $3 billion to date. Clinicians and policy experts have raised concerns that the 30-day readmission measure used in this program provides an incomplete picture of performance because it does not capture all hospital encounters that may occur after discharge. In contrast, the excess days in acute care (EDAC) measure, which currently is not used in the HRRP, captures the full spectrum of hospital encounters (emergency department, observation stay, inpatient readmission) and their associated lengths of stay within 30 days of discharge. This study of 3173 hospitals that participated in the HRRP in fiscal year 2019 compared performance on the readmission and EDAC measures and evaluated whether using the EDAC measure would change hospitals' penalty status for 3 conditions targeted by the HRRP. Overall, only moderate agreement was found on hospital performance rankings by using the readmission and EDAC measures (weighted κ statistic: heart failure, 0.45 [95% CI, 0.42 to 0.47]; acute myocardial infarction [AMI], 0.37 [CI, 0.35 to 0.40]; and pneumonia, 0.50 [CI, 0.47 to 0.52]). Under the HRRP, the penalty status of 769 (27.0%) of 2845 hospitals for heart failure, 581 (28.3%) of 2055 for AMI, and 724 (24.9%) of 2911 for pneumonia would change if the EDAC measure were used instead of the readmission measure to evaluate performance. Fewer small and rural hospitals would receive penalties. The Centers for Medicare & Medicaid Services should consider using the EDAC measure, which provides a more comprehensive picture of postdischarge hospital use, rather than the 30-day readmission measure to evaluate health care system performance under federal quality, reporting, and value-based programs.


Assuntos
Economia Hospitalar , Hospitais/estatística & dados numéricos , Readmissão do Paciente/tendências , Idoso , Feminino , Humanos , Masculino , Alta do Paciente/tendências , Estados Unidos
20.
Mycoses ; 64(1): 86-94, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33034927

RESUMO

BACKGROUND: Isavuconazole (ISA) is a frequently used antifungal agent for the treatment of invasive fungal diseases (IFDs). However, hospital reimbursement data for ISA is limited. OBJECTIVES: The primary objective of this study was to analyse the different perspectives of relevant stakeholders and the (dis)incentives for the administration of ISA in Germany. To that aim, the health economic effects of using ISA from a hospital management perspective were analysed. PATIENTS/METHODS: Based on principal-agent theory (PAT), the perspectives of (a) the patient (principal) as well as (b) physicians, (c) pharmacists and iv. hospital managers (all agents) were analysed. For the evaluation of the cost-containment and reimbursement strategies of ISA, the German diagnosis-related group (G-DRG) system was used. RESULTS: Hospitals individually negotiating additional payments for innovative treatment procedures (zusatzentgelte [ZE]) within the G-DRG system is a key element of hospital management for the reduction of total healthcare expenditure. Our analysis demonstrated the beneficial role of ISA in healthcare resource utilisation, primarily due to a shortened overall length of hospital stay. Depending on underlying disease, coded G-DRG and ISA formulation, large differences in total reimbursement and the amount of ZE was shown. The PAT demonstrated disincentives for hospital managers to use innovative drugs. CONCLUSIONS: Based on the PAT, beneficial, detrimental and indifferent perspectives of different stakeholders regarding the usage of ISA were shown. A reduction of bureaucratic hurdles is needed in Germany for the extension of effective and innovative antifungal treatment strategies with ISA.


Assuntos
Custos e Análise de Custo , Hospitais , Nitrilas/uso terapêutico , Piridinas/uso terapêutico , Triazóis/uso terapêutico , Análise Custo-Benefício , Grupos Diagnósticos Relacionados/economia , Economia Hospitalar , Alemanha , Humanos , Tempo de Internação/economia , Nitrilas/administração & dosagem , Nitrilas/economia , Piridinas/administração & dosagem , Piridinas/economia , Triazóis/administração & dosagem , Triazóis/economia
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