Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance.

BACKGROUND: Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures. METHODS: In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations. RESULTS: The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%. CONCLUSIONS: This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.).

Trends in Volume and Charges of Retinal Tear Patients in the Emergency Department.

PURPOSE: To characterize retinal tears (RTs) and calculate the economic burden of RTs that present to the emergency department (ED) in the US. METHODS: We used a large national ED database to retrospectively analyze RTs that presented to the ED from 2006 to 2019. Using extrapolation methods, national of the RT patient ED volume, demographics, comorbidities, disposition, inpatient (IP) charges, and ED charges were calculated. RESULTS: During the period between 2006 and 2019, 15841 ED encounters had RT listed as the primary diagnosis. The average annual RT ED encounters was 2,640 ± 856 and comprised an average of 6.4 × 10-5% of all ED visits annually. The number and ED percentage of RT encounters did not change during this time period (p = .22, p = .67, respectively). Most patients were males, Caucasian, paid with private insurance, and admitted to EDs in the Northeast. The most common comorbidities were hypertension (19%), a history of cataracts (15%), and diabetes (7.2%). During this time period, RTs charges added up to more than $79 million and $33 million in the ED and IP settings, respectively. Mean per-encounter ED and IP charges increased by 145% (p = .0008) and 86% (p = .0047), respectively. CONCLUSION: Despite the stable number of RT patients presenting to the ED, RTs place a significant economic burden to the healthcare system, which increases yearly. We recommend physicians and policy makers to work together to pass laws that could prevent the increasing healthcare charges.

Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients.

INTRODUCTION: We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis. METHODS: Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated. RESULTS: Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis. CONCLUSION: Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.

Reported Variation in Hospital Billing Quality.

This study examines how US hospitals perform on billing quality measures, including legal actions taken by a hospital to collect medical debt, the timeliness of sending patients an itemized billing statement, and patient access to a qualified billing representative.

Ongoing Challenges With Price Transparency in Hospital Charges for Hand Procedures.

In 2020, the Centers for Medicare & Medicaid Services issued a historic rule on price transparency that aimed to better inform Americans about their health care costs by requiring hospitals to publicly provide pricing information on their items and services. In this review article, we describe the current gaps in transparency that persist after the implementation of the rule, from incomplete pricing files to noncompliance despite the issuance of monetary penalties by Centers for Medicare & Medicaid Services. Price transparency is vital for hand and upper extremity procedures, given their cost variation and patient desire for more financial discussions with their physicians regarding these procedures. Further improvements and interventions by various stakeholders are necessary to improve the current state of hospital price transparency and cost information for these patients and for anyone who seeks to make informed health care decisions. Policymakers should enforce stronger financial interventions and penalties and promote the use of bundled payments to facilitate better compliance by hospitals through a more expanded and accessible display of health care service costs. To help increase health care financial literacy among consumers, hand surgeons and hospital staff should engage in more dialog regarding health care prices and financial considerations with their patients.

Regional differences in the utilization and outcomes of cerebral embolic protection during transcatheter aortic valve replacement: an analysis of the National Inpatient Sample from 2017 through 2019.

Aim: To evaluate the utilization and outcomes of cerebral embolic protection (CEP) during transcatheter aortic valve replacement (TAVR) by USA region, using discharge data from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Patients & methods: All TAVR discharge encounters from June 2017-2019 were included in the analysis. Discharge encounters with bicuspid anatomy were excluded. Regional CEP utilization rates were reported. For TAVR cases performed with the Sentinel CEP device (Boston Scientific, MA, USA), multivariable logistic regression was performed to model regional differences in TAVR outcomes including: stroke, transient ischemic attack (TIA), stroke/TIA combined, and in-hospital all-cause mortality. Generalized linear regression models were used to assess regional differences in length of stay (LOS) and hospital charges. Results: The Northeast had the greatest overall CEP utilization rate (11.3%), followed by the Midwest (11.1%), West (8.7%), then South (3.1%). Compared with the Northeast, the South was associated with a lower risk of stroke (OR: 0.267, 95% CI: 0.106-0.673; p = 0.005), and the West a higher risk of stroke (OR: 1.583, 95% CI: 1.044-2.401; p = 0.031). Compared with the Northeast, the West was associated with a higher risk of stroke/TIA combined (OR: 1.618, 95% CI: 1.107-2.364; p = 0.013). Compared with the Northeast, the Midwest (OR: 4.501, 95% CI: 2.229-9.089; p < 0.001) and West (OR: 5.316, 95% CI: 2.611-10.824; p < 0.001) were associated with a higher risk of in-hospital all-cause mortality. Adjusted charges and LOS were highest in the West. Conclusion: Within the USA, there are regional differences in the utilization and outcomes of CEP use during TAVR. To prevent regional disparities and ensure consistent quality of care in the USA, further research is needed to determine what variable(s) may be responsible for regional differences in TAVR outcomes, with or without CEP.

Laser enucleation of the prostate (LEP) vs. simple prostatectomy: an analysis of hospital charges and comparison of practice trends.

PURPOSE: Laser enucleation of the prostate (LEP) and simple prostatectomy (SP) are surgical treatment options for large gland Benign Prostatic Hyperplasia. While multiple studies compare clinical outcomes of these procedures, there are limited data available comparing hospital charges in the United States. Here, we present current practice trends and a hospital charge analysis on a national level using an annual insurance claims data repository. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample and Nationwide Ambulatory Surgery Sample databases for 2018 were queried. CPT and ICD-10PCS codes identified patients undergoing LEP or SP, who were then compared for practice setting, total hospital charges, and payor. Laser type for LEP and surgical approach for SP could not be differentiated. RESULTS: The median hospital charge of 5782 LEPs and 973 SPs is $26,689 and $51,250 (p < 0.001), respectively. LEP independently predicts a decreased hospital charge of $16,464 (p < 0.001) per case. Medicare is the primary payor for both procedures. More LEP procedures are completed in the outpatient setting (87.8%) vs. SPs (5.7%, p < 0.001). Median length of stay is longer for SP (LEP: 0, IQR: 0; SP: 3, IQR: 2-4; p < 0.001). In the Western region, LEP is least commonly performed (184, p < 0.001), most expensive ($43,960; p < 0.001), and has longer length of stay (2, p < 0.001). CONCLUSIONS: LEP should be considered a cost-effective alternative to SP. Regions of the U.S. that perform more LEPs have shorter length of stay and lower hospital charges associated with the procedure.

Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure.

OBJECTIVES: The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS: This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS: There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS: Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.

Descriptions and Changes in Charge Master Pricings of US Children's Hospitals From 2019 to 2021.

BACKGROUND AND OBJECTIVES: A lack of price transparency may contribute to high healthcare costs. US hospitals were mandated to post their charge masters online in 2019. To compare changes in charge master prices of 3 common tests (complete blood count, complete metabolic panel, and chest radiograph) at US children's hospitals between 2019 and 2021. METHODS: Online search for charge master was conducted from July to December 2019 and October to December 2021. Descriptive statistics were reported for each test. Prices between years were adjusted for inflation and compared with paired t test. City-level variation was evaluated by comparing the coefficient of variation in 6 metropolitan areas: Baltimore, California Bay Area, Chicago, Dallas-Fort Worth, Los Angeles, and New York City. RESULTS: Of 847 hospitals, charge masters were found in 747 (88%) in 2021 and 728 (86%) in 2019. Complete blood count prices ranged from $5 to $1037 in 2019 and $5 to $1085 in 2021, with no difference between the 2 years (P = .17). Complete metabolic panel prices ranged from $10 to $2440 in 2019 and $6 to $2746 in 2021, with no difference in prices (P = .75). Chest radiograph prices ranged from $20 to $1900 in 2019 compared with $30 to $5800 in 2021. Prices were higher compared with 2019 ($392 vs. $365, P < .0006). City-level changes in the coefficient of variation showed only 2 cities with reduced coefficients of variation in all 3 tests. CONCLUSIONS: Two years after mandating hospitals post charge masters online, there continues to be tremendous variability in prices of common tests across US children's hospitals.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Demystifying hospital charges for hospital readmissions in 2017 in the United States for psychosis (DRG = 885).

Existing research on hospital charges is primarily focused on hospital admissions, but not on hospital readmissions. Our research fills this gap. We utilize the 2017 Hospital Readmissions database from the Agency for Healthcare Research and Quality (AHRQ) to empirically study factors that impact hospital charges for hospital readmissions. We focus on psychosis (DRG = 885) which has 609,360 records in 2017 in the AHRQ database. We employ regression analyses using patient demographics, inpatient care variables, and hospital characteristics to explain variance in hospital charges. Results show that inpatient care (diagnoses, procedures, length of stay), hospital ownership, and younger patients result in higher hospital charges.

The Divergence Between Hospital Charges and Reimbursements For Primary 1-2-level Lumbar Fusion Has Increased Over Time: A Medicare Administrative Claims Analysis.

STUDY DESIGN: A retrospective cohort study was performed for patients undergoing 1-2-level lumbar fusion (1-2LF) from 2005 to 2014 using an administrative claims database. OBJECTIVE: The objective of this study was to determine changes in: (1) annual charges; (2) annual reimbursement rates; and (3) annual difference (charges minus reimbursements) in patients undergoing 1-2LF. SUMMARY OF BACKGROUND DATA: With implementation of value-based care in orthopaedics, coupled with the rise in number of patients undergoing 1-2LF, understanding the discordance in hospital charges and reimbursements is needed. The difference in hospital charges to reimbursements specifically for 1-2LF for degenerative disc disease has not been studied. MATERIALS AND METHODS: A Medicare administrative claims database was queried for patients undergoing primary lumbar fusion using ICD-9 procedural code 81.04-81.08. Patients specifically undergoing 1-2LF were filtered from this cohort using ICD-9 procedural code 81.62. The query yielded 547,067 patients who underwent primary 1-2LF. Primary outcomes analyzed included trends in charges, reimbursement rates, and net difference in cost over time and per annual basis. Linear regression evaluated the change in costs over time with a P -value less than 0.05 considered significant. RESULTS: From 2005 to 2014, total charges increased from $6,085,838,407 to $19,621,979,956 and total reimbursements increased from $1,677,764,831 to $4,656,702,685 (all P <0.001). Per patient charges increased 92.10% from 2005 to 2014 for patients undergoing primary 1-2LF from $129,992 to $249,697 ( P <0.001). Similarly, an increase in reimbursement per patient of 65.35% from $35,836 to $59,258 ( P <0.001) was noted. The annual difference in charges to reimbursements increased 102.26% during the study interval from $94,155 to $190,439 ( P <0.001). CONCLUSIONS: Per patient charges and reimbursements both increased over the study period; however, charges increased 30% more than reimbursements. Further breakdown of hospital, surgeon, and anesthesiologist reimbursements for 1-2LF is needed. LEVEL OF EVIDENCE: Level III.

Retrospective cohort study comparing surgical inpatient charges, total costs, and variable costs as hospital cost savings measures.

We analyzed differences (charges, total, and variable costs) in estimating cost savings of quality improvement projects using reduction of serious/life-threatening complications (Clavien-Dindo Level IV) and insurance type (Private, Medicare, and Medicaid/Uninsured) to evaluate the cost measures. Multiple measures are used to analyze hospital costs and compare cost outcomes across health systems with differing patient compositions. We used National Surgical Quality Improvement Program inpatient (2013-2019) with charge and cost data in a hospital serving diverse socioeconomic status patients. Simulation was used to estimate variable costs and total costs at 3 proportions of fixed costs (FC). Cases (Private 1517; Medicare 1224; Medicaid/Uninsured 3648) with patient mean age 52.3 years (Standard Deviation = 14.7) and 47.3% male. Medicare (adjusted odds ratio = 1.55, 95% confidence interval = 1.16-2.09, P = .003) and Medicaid/Uninsured (adjusted odds ratio = 1.41, 95% confidence interval = 1.10-1.82, P = .008) had higher odds of complications versus Private. Medicaid/Uninsured had higher relative charges versus Private, while Medicaid/Uninsured and Medicare had higher relative variable and total costs versus Private. Targeting a 15% reduction in serious complications for robust patients undergoing moderate-stress procedures estimated variable cost savings of $286,392. Total cost saving estimates progressively increased with increasing proportions of FC; $443,943 (35% FC), $577,495 (50% FC), and $1184,403 (75% FC). In conclusion, charges did not identify increased costs for Medicare versus Private patients. Complications were associated with > 200% change in costs. Surgical hospitalizations for Medicare and Medicaid/Uninsured patients cost more than Private patients. Variable costs should be used to avoid overestimating potential cost savings of quality improvement interventions, as total costs include fixed costs that are difficult to change in the short term.

Is Hospital Hospice Service Associated with Efficient Healthcare Utilization in Deceased Lung Cancer Patients? Hospital Charges at Their End of Life.

In July 2015, South Korea began applying National Health Insurance reimbursement to inpatient hospice service. It is now appropriate and relevant to evaluate how hospice care is associated with healthcare utilization in terminal lung cancer patients. We used nationwide NHI claims data of lung cancer patients from 2008-2018 and identified a sample of patients deceased after July 2016. We transposed the dataset into a retrospective cohort design where a unit of analysis was each lung cancer patients' healthcare utilization. The differences in hospital charges per day were investigated depending on the patient's use of hospice service before death with the Generalized Linear Model (GLM) analysis. Additionally, subgroup analysis and the propensity score matching method were used to validate the model using the claims information of 25,099 patients. About 17.0% of patients used hospice services (N = 4260). With other variables adjusted, hospice service utilization by deceased lung cancer patients was associated with statistically significant lower hospital charges per day at the end of life (1 month, 3 months, and 6 months before death) compared to non-users. A similar trend was found in the propensity score matching model analysis. We found lower end-of-life hospital charges per day among lung cancer patients who received hospice services near death. The ever-expanding aging population requires health policymakers and the National Health Insurance program to expand hospice services for terminal cancer patients in underserved regions and hospitals that do not provide hospice.

Collection of economic data using UB-04s: Is it worth the effort? Evidence from two clinical trials.

Cost collection using UB-04 forms for economic evaluation is challenging, as UB-04 collection is time and effort intensive and compliance is imperfect. Alternative data sources could overcome those challenges. The objective of this study is to determine the usefulness of UB-04 data in estimating hospital costs compared to clinical case report form (CRF) data. Health care utilization costs were compared from financial information in UB-04s and from an assignment process using CRF data, from the WRAP-IT (23 infections) and the Micra IDE trials (61 adverse events and 108 implants). Charge-based costs were calculated by multiplying charges in UB-04s and hospital-specific Cost-to-Charge ratios from the Centers for Medicare and Medicaid Services cost reports. The cost assignment process used clinical information to find comparable encounters in real world data and assigned an average cost. Paired difference tests evaluated whether both methods yield similar results. The mean difference in total infection related costs between methods in the WRAP-IT trial was $152 +/-$22,565. In the Micra IDE trial, the mean difference in total adverse event related costs between methods was -$355 +/-$8,298 while the mean difference in total implant related costs between methods was $-3,488 +/-$13,859. Wilcoxon tests and generalized linear models could not reject the difference in costs between methods in the first two cases. Cost assignment methods achieve results similar to costs obtained through UB-04s, without the additional investment in time and effort. The use of UB-04 information for services that are not mature in a health care system may present unexpected challenges, necessitating a tradeoff with other methods of cost assignment.

Motor Vehicle Crash and Hospital Charges in Front- and Rear-Seated Restrained and Unrestrained Adult Motor Vehicle Occupants.

There are reports that historically higher mortality observed for front- compared to rear-seated adult motor vehicle (MV) occupants has narrowed. Vast improvements have been made in strengthening laws and restraint use in front-, but not rear-seated occupants suggesting there may be value in expanding the science on rear-seat safety. METHODS: A linked 2016-2017 hospital and MV crash data set, the Crash Outcomes Data Evaluation System (CODES), was used to compare characteristics of front-seated (n = 115,939) and rear-seated (n = 5729) adults aged 18 years and older involved in a MV crash in New York State (NYS). A primary enforced seat belt law existed for front-seated, but not rear-seated occupants. Statistical analysis employed SAS 9.4. RESULTS: Compared to front-seated occupants, those rear-seated were more likely to be unrestrained (21.2% vs. 4.3%, p < 0.0001) and to have more moderate-to-severe injury/death (11.9% vs. 11.3%, p < 0.0001). Compared to restrained rear-seated occupants, unrestrained rear-seated occupants had higher moderate-to-severe injury/death (21.5% vs. 7.5%, p < 0.0001) and 4-fold higher hospitalization. More than 95% of ejections were unrestrained and had 7-fold higher medical charges. Unrestrained occupants' hospital stays were longer, charges and societal financial costs higher. CONCLUSIONS: These findings extend the science of rear-seat safety in seriously injured rear-seated occupants, document increased medical charges and support the need to educate consumers and policy makers on the health and financial risks of adults riding unrestrained in the rear seat. The lack of restraint use in adult rear-seated motor vehicle occupants consumes scarce health care dollars for treatment of this serious, but largely preventable injury.

Utilization Trends, Cost, and Payments for Adult Spinal Deformity Surgery in Commercial and Medicare-Insured Populations.

BACKGROUND: Previous studies have characterized utilization rates and cost of adult spinal deformity (ASD) surgery, but the differences between these factors in commercially insured and Medicare populations are not well studied. OBJECTIVE: To identify predictors of increased payments for ASD surgery in commercially insured and Medicare populations. METHODS: We identified adult patients who underwent fusion for ASD, 2007 to 2015, in 20% Medicare inpatient file (n = 21 614) and MarketScan commercial insurance database (n = 38 789). Patient age, sex, race, insurance type, geographical region, Charlson Comorbidity Index, and length of stay were collected. Outcomes included predictors of increased payments, surgical utilization rates, total cost (calculated using Medicare charges and hospital-specific charge-to-cost ratios), and total Medicare and commercial payments for ASD. RESULTS: Rates of fusion increased from 9.0 to 8.4 per 10 000 in 2007 to 20.7 and 18.2 per 10 000 in 2015 in commercial and Medicare populations, respectively. The Medicare median total charges increased from $88 106 to $144 367 (compound annual growth rate, CAGR: 5.6%), and the median total cost increased from $31 846 to $39 852 (CAGR: 2.5%). Commercial median total payments increased from $58 164 in 2007 to $64 634 in 2015 (CAGR: 1.2%) while Medicare median total payments decreased from $31 415 in 2007 to $25 959 in 2015 (CAGR: -2.1%). The Northeast and Western regions were associated with higher payments in both populations, but there is substantial state-level variation. CONCLUSION: Rate of ASD surgery increased from 2007 to 2015 among commercial and Medicare beneficiaries. Despite increasing costs, Medicare payments decreased. Age, length of stay, and BMP usage were associated with increased payments for ASD surgery in both populations.

An examination of the most expensive adult hospitalizations in America.

BACKGROUND: While no hospitalization is inexpensive, some are extremely costly. Learning from these exceptions is critical. The patients and conditions that ultimately translate into the most exorbitant adult hospitalizations have not been characterized. OBJECTIVE: To analyze and detail characteristics of extreme high-cost adult hospitalizations in the United States using the most recently available Nationwide Inpatient Sample (NIS) data. DESIGN/SETTING/PARTICIPANTS: The NIS 2018 database was queried for all adult hospitalizations with hospital charges greater than $333,000. Multivariable linear regression was used in the analyses. MEASURES: The main outcome measures were total charges, mortality, length of stay, admitting diagnosis, and procedures. RESULTS: There were 538,121 adults age ≥18 years with total hospital charges ≥$333,333. Among these patients 481,856 (89.5%) survived their hospitalization and 56,265 (10.4%) died. Males, older patients, being insured by Medicare, having more comorbid illness, and those who were transferred from another hospital were significantly more likely to die during the incident hospitalization (all p < 0.01). Patients who died had even more costly hospitalizations with more procedures (mean [SD]: 10.7 [±6.4] versus 7.0 [± 5.9], p < 0.01), and longer lengths of stay after adjustment for confounders (p = 0.01). CONCLUSIONS: Hundreds of thousands of adult patients are hospitalized in the US each year at extremely high costs. For both those who survive and the 10% who die, there may be opportunities for reducing the expense. Interventions, such as predictive modeling and systematic goals of care discussions with all patients, deserve further study.