Emergency Medicaid Acquisition Through the Affordable Care Act: The Association Between Hospital Enrollment in California and Hospital Revenue.

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.

Collaboration, Not Calculation: A Qualitative Study of How Hospital Executives Value Hospital Medicine Groups.

BACKGROUND: Hospital medicine groups (HMGs) typically receive financial support from hospitals. Determining a fair amount of financial support requires negotiation between HMG and hospital leaders. As the hospital medicine care model evolves, hospital leaders may regularly challenge HMGs to demonstrate the financial value of activities that do not directly generate revenue. OBJECTIVE: To describe current attitudes and beliefs of hospital executives regarding the value of contributions made by HMGs. DESIGN: Thematic content analysis of key informant interviews. PARTICIPANTS: Twenty-four healthcare institutional leaders, including hospital presidents, chief medical officers, chief executive officers, and chief financial officers. Participants comprised a diverse sample from all regions in the United States, including rural, suburban, and urban locations, and academic and nonacademic institutions. RESULTS: Executives highly valued hospitalist groups that demonstrate alignment with hospital priorities, and often used this concept to summarize the HMG's success across several value domains. Most executives evaluated only a few key HMG metrics, but almost no executives reported calculating the HMG return on investment by summing pertinent quantitative contributions. Respondents described an evolving concept of hospitalist value and believed that HMGs generate substantial value that is difficult to measure financially. CONCLUSIONS: Hospital executives appear to make financial support decisions based on a small number of basic financial or care quality metrics combined with a subjective assessment of the HMG's broader alignment with hospital priorities. HMG leaders should focus on building relationships that facilitate dialog about alignment with hospital needs.

The logistics of an inpatient dermatology service.

Inpatient dermatology represents a unique challenge as caring for hospitalized patients with skin conditions is different from most dermatologists' daily outpatient practice. Declining rates of inpatient dermatology participation are often attributed to a number of factors, including challenges navigating the administrative burdens of hospital credentialing, acclimating to different hospital systems involving potential alternate electronic medical records systems, medical-legal concerns, and reimbursement concerns. This article aims to provide basic guidelines to help dermatologists establish a presence as a consulting physician in the inpatient hospital-based setting. The emphasis is on identifying potential pitfalls, problematic areas, and laying out strategies for tackling some of the challenges of inpatient dermatology including balancing financial concerns and optimizing reimbursements, tracking data and developing a plan for academic productivity, optimizing workflow, and identifying metrics to document the impact of an inpatient dermatology consult service.

A matter of priorities? Exploring the persistent gender pay gap in hospital medicine.

BACKGROUND: Gender earnings disparities among physicians exist even after considering differences in specialty, part-time status, and practice type. Little is known about the role of job satisfaction priorities on earnings differences. OBJECTIVE: To examine gender differences in work characteristics and job satisfaction priorities, and their relationship with gender earnings disparities among hospitalists. DESIGN: Observational cross-sectional survey study. PARTICIPANTS: US hospitalists in 2010. MEASUREMENTS: Self-reported income, work characteristics, and priorities among job satisfaction domains. RESULTS: On average, women compared to men hospitalists were younger, less likely to be leaders, worked fewer full-time equivalents, worked more nights, reported fewer daily billable encounters, more were pediatricians, worked in university settings, worked in the Western United States, and were divorced. More hospitalists of both genders prioritized optimal workload among the satisfaction domains. However, substantial pay ranked second in prevalence by men and fourth by women. Women hospitalists earned $14,581 less than their male peers in an analysis adjusting for these differences. CONCLUSIONS: The gender earnings gap persists among hospitalists. A portion of the disparity is explained by the fewer women hospitalists compared to men who prioritize pay.

The evolving role of the pediatric nurse practitioner in hospital medicine.

BACKGROUND: This program evaluation sought to compare cost and pediatric patient outcomes among a pediatric nurse practitioner (PNP) hospitalist team, a combined PNP/doctor of medicine (MD) team, and 2 resident teams without PNPs. METHODS: Administrative and electronic medical record data from July 1, 2009 to June 30, 2010 was retrospectively reviewed from Children's Hospital Colorado inpatient medical unit and inpatient satellite sites in the Children's Hospital network of care (NOC). The top 3 All Patient Refined Diagnosis Related Groups (APR-DRG) admission codes bronchiolitis and respiratory syncytial virus (RSV) pneumonia, pneumonia not elsewhere classified (NEC), and asthma were selected for this analysis. Inpatient records representing these APR-DRG admission codes were reviewed (N = 1664). Measures included adherence with relevant clinical care guidelines (CCGs), length of stay (LOS), and cost of care. Chi square, t tests, and analysis of variance were used to analyze between-group differences. RESULTS: Approximately 20% of these admissions were on the PNP team, 45% were on the resident teams, and 35% were on the PNP/MD team in the NOC. PNP adherence to CCGs was comparable to resident teams for selected measures. There was no significant difference in LOS among the PNP team, the PNP/MD team, and the resident teams. The direct cost of patient care per encounter provided by the PNP team was significantly less than the PNP/MD team and the resident teams. CONCLUSIONS: There is evidence to suggest that PNP hospitalists provide inpatient care comparable to resident teams at a lower cost for patients with uncomplicated bronchiolitis, pneumonia, and asthma.

Successful implementation of a referral-based academic pediatric hospitalist service.

OBJECTIVE: St Louis Children's Hospital (SLCH) developed Service for Hospital Admissions by Referring Physicians (SHARP) in January 2008 as an inpatient referral service for pediatricians who previously admitted their own patients. We hypothesized that use of SHARP would make hospitalization more efficient and cost-effective compared with the general pediatric medicine (GM) service. METHODS: Admission volumes, diagnoses, length of stay (LOS), costs, and physician billing data were abstracted from SLCH information systems and the Pediatric Health Information System database. We compared admissions for SHARP and GM from January 2008 through June 2010. RESULTS: SHARP had lower LOS and costs versus GM, with no change in 7-day readmission rate. Median LOS was 2 days for SHARP and 3 days for GM (P<.001). Median hospital cost per patient was $2719 for SHARP and $3062 for GM (P<.001). Over the study period, the admission rate increased 37% and daily patient encounters increased 39%. Physician billing revenue increased 25% in the first 6 months, then continued to increase steadily. Total physicians and geographic referral area using SHARP increased, and referring physician satisfaction was high. CONCLUSIONS: SHARP approaches financial independence and provides a cost savings to SLCH. LOS decreased by a statistically significant amount compared with GM with no change in readmission rate. Referring physician satisfaction was high, likely allowing for growth in referrals to SLCH. SHARP hospitalists' collaboration with referring physicians, ensuring excellent follow-up, provides decreased duration of hospitalization and resource utilization. Our availability throughout the day to reassess patients increases efficiency. We project that we must average 12.6 daily encounters to be financially independent.

Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery.

OBJECTIVE: The goal of this study was to assess outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis. METHODS: A hospitalist comanagement program was implemented at a children's hospital. We conducted a retrospective case series study of patients during 2003-2008 to compare clinical and cost outcomes for 87 preimplementation patients, 40 patients during a partially implemented program, and 80 patients during a fully implemented program. RESULTS: When compared with preimplementation patients, full implementation program patients did not demonstrate a statistically significant difference in median length of stay on the medical/surgical unit after transfer from the PICU (median: 6 vs 8 days; P = .07). Patients in the full implementation group received fewer days of parenteral nutrition (median: 0 vs 6 days; P = .0006) and had fewer planned and unplanned laboratory studies on the inpatient unit. There was no statistically significant change in returns to the operating room (P = .08 between preimplementation and full implementation), other complications, or 30-day readmissions. Median hospital costs increased from preimplementation ($59372) to partial implementation ($89302) and remained elevated during full implementation ($81 651) compared with preimplementation (P = .004). Mean physician costs followed a similar trajectory from preimplementation ($18425) to partial implementation ($24101) to full implementation ($22578; P = .0006 [versus preimplementation]). CONCLUSIONS: A hospitalist comanagement program can significantly affect the care of medically complex children undergoing spinal fusion surgery. Initial program costs may increase.

[Hospital medicine in Chile]. / Medicina hospitalaria a 15 años de su implementación: ¿Cuáles son los potenciales beneficios en nuestro medio?

After 15 years of development of Hospital Medicine in Chile, there are several benefits of this discipline. Among others, a reduction in the length of hospital stay, readmissions, costs, and improved medical teaching of students, residents and fellows have been observed. However, in South América there are only isolated groups dedicated to Hospital Medicine in Chile, Argentina and Brazil, with a rather slow growth. The unjustified fear of competition from sub specialists, and the fee for service system of payment in our environment may be important factors to understand this phenomenon. The aging of the population makes imperative to improve the safety of our patients and to optimize processes and resources within the hospital, to avoid squandering healthcare resources. The following is a detailed and evidence-based article, on how hospital medicine might benefit both the public and prívate healthcare systems in Chile.

Medicina hospitalaria a 15 años de su implementación: ¿Cuáles son los potenciales beneficios en nuestro medio? / Hospital medicine in Chile

After 15 years of development of Hospital Medicine in Chile, there are several benefits of this discipline. Among others, a reduction in the length of hospital stay, readmissions, costs, and improved medical teaching of students, residents and fellows have been observed. However, in South América there are only isolated groups dedicated to Hospital Medicine in Chile, Argentina and Brazil, with a rather slow growth. The unjustifiedfear of competitionfrom sub specialists, and the fee for service system ofpayment in our environment may be importantfactors to understand this phenomenon. The aging of the population makes imperative to improve the safety of our patients and to optimize processes and resources within the hospital, to avoid squandering healthcare resources. The following is a detailed and evidence-based article, on how hospital medicine might benefit both thepublic and prívate healthcare systems in Chile.