Legislating Nurse Staffing: Projected Impact on Hospital Economics, Process Flow, and Hospital-Associated Infections in Montana.

OBJECTIVE: The aim of this study was to project the impact of legislated nurse staffing ratios on patient-, staff-, and system-level outcomes for Prospective Payment System (PPS) hospitals in Montana. BACKGROUND: In 2023, House Bill 568 was introduced in Montana focused on legislating hospital safe nursing standards. METHODS: A quantitative design was used for a convenience sample of Montana PPS hospitals. Data were gathered through a newly developed survey and from other publicly available sources for the years 2018 to 2022. Independent t tests were conducted when appropriate with the significance threshold set at 0.05. RESULTS: Projections indicate no significant change in patient outcome metrics accompanied by increases in labor requirements, slower emergency department throughput times, and decreases in hospital operating margins. CONCLUSIONS: In Montana, legislating nurse staffing ratios would have downstream implications inconsistent with the intended impact on patient safety, emphasizing the complexity of variables within and external to the healthcare system that drive patient-, staff-, and system-level outcomes.

Hospital strategies in commercial episode-based reimbursement.

OBJECTIVES: To understand hospitals' approaches to spending reduction in commercial episode-based payment programs and inform incentive design. STUDY DESIGN: Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state's largest commercial payer. METHODS: We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference-based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains. RESULTS: Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment. CONCLUSIONS: The findings highlighted hospitals' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.

Relationship between profitability and financial factors of hospitals after a period of austerity and health care reforms: evidence from Greece.

PURPOSE: The reduction of government expenditure in the healthcare system, the difficulty of finding new sources of funding and the reduction in disposable income per capita are the most important problems of the healthcare system in Greece over the last decade. Therefore, studying the profitability of health structures is a crucial factor in making decisions about their solvency and corporate sustainability. The aim of this study is to investigate the effect of economic liquidity, debt and business size on profitability for the Greek general hospitals (GHs) during the period 2016-2018. DESIGN/METHODOLOGY/APPROACH: Financial statements (balance sheets and income statements) of 84 general hospitals (GHs), 52 public and 32 private, over a three-year period (2016-2018), were analyzed. Spearman's Rs correlation was carried out on two samples. FINDINGS: The results revealed that there is a positive relationship between the investigated determinants (liquidity, size) and profitability for both public and private GHs. It was also shown that debt has a negative effect on profitability only for private GHs. PRACTICAL IMPLICATIONS: Increasing the turnover of private hospitals through interventions such as expanding private health insurance and adopting modern financial management techniques in public hospitals would have a positive effect both on profitability and the efficient use of limited resources. ORIGINALITY/VALUE: These results, in conjunction with the findings of the low profitability of private hospitals and the excess liquidity of public hospitals, can shape the appropriate framework to guide hospital administrators and government policymakers.

Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium.

BACKGROUND: Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time. METHODS: The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time. RESULTS: Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme. CONCLUSIONS: The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program.

Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Pricing of hospital services: evidence from a thematic review.

The management implications of pricing healthcare services, especially hospitals, have received insufficient scholarly attention. Additionally, disciplinary overlaps have led to scattered academic efforts in this domain. This study performs a thematic synthesis of the literature and applies retrospective analysis to hospital service pricing articles to address these issues. The study's inputs were sourced from well-known online repositories, using a structured search string and PRISMA flow chart to select the pertinent documents. Our thematic analysis of pricing literature encompasses: (a) comprehension of hospital service pricing nature; (b) pricing objectives, strategies and practices differentiation; (c) presentation of factors impacting hospital service pricing. We observe that hospital pricing is an intricate and unclear matter. The terms 'pricing strategies' and 'pricing practices' are often used interchangeably in academic literature. Hospital service pricing is influenced by costs, demand and supply factors, market structure, pricing regulation and third-party reimbursements. The study's findings provide policy implications for service pricing in hospitals, in addition to suggesting avenues for future research on hospital pricing.

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.).

Uncompensated Care is Highest for Rural Hospitals, Particularly in Non-Expansion States.

High levels of uncompensated care impact hospital profitability and may create challenges for rural hospitals at financial risk of closure. We explore 2019 hospital uncompensated care as a percentage of operating expenses and draw comparisons at a state level by Medicaid expansion status and rural classification. We further compare uncompensated care in 2019 to 2014 in rural hospitals by Medicaid expansion implementation timing. We found that, overall, rural hospitals had more uncompensated care than urban hospitals in 2019 (3.81% vs. 3.12%), but there was a larger difference by expansion status (expansion states: 2.55% vs. non-expansion states: 6.28%). In all but seven states, rural hospitals reported higher uncompensated care than urban, and the 14 states with the highest uncompensated care had not expanded Medicaid. We observed that rural hospital uncompensated care in non-expansion states increased between 2014 and 2019, while the most dramatic decrease occurred in late-expansion states.

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.

Prices for Common Services at Quaternary vs Nonquaternary Hospitals.

This study uses commercial claims data to assess whether quaternary hospitals charge higher prices for common, unspecialized services also offered by nonquaternary hospitals.

Use of hand-held ultrasound to perform E-FAST by general surgery residents in a trauma reference center: First experience in the Colombian Caribbean region / Uso de ecografía portátil para realizar E-FAST por residentes de cirugía general en un centro de referencia en trauma: primera experiencia en la región del Caribe colombiano

Introduction. Extended focused assessment with sonography for trauma (E-FAST) can be performed with minimal training and achieve ideal results. It allows easy transport and use in austere environments such as the Colombian Caribbean, where many centers do not have 24-hour radiology services. The objective of this study was to determine the performance of the use of E-FAST in the evaluation of trauma by second-year general surgery residents in the emergency department. Methods. Retrospective observational study that evaluated the diagnostic performance of E-FAST with Butterfly IQ, in patients with thoracoabdominal trauma, who attended a referral center in the Colombian Caribbean between November 2021 and July 2022. Sensitivity, specificity, and positive and negative predictive values were evaluated, compared with intraoperative findings or conventional imaging. Results. A total of 46 patients were included, with a mean age of 31.2 ± 13.8 years, 87.4% (n=39) were male. The main mechanism of trauma was penetrating (n=32; 69.5%). It was found that 80.4% (n=37) of the patients had a positive E-FAST result, and of these, 97% (n=35) had a positive intraoperative finding. Sensitivity, specificity, positive predictive value and negative predictive value were 92.1%, 75%, 94.6%, and 66.6%, respectively. The positive likelihood ratio was 3.68, while the negative likelihood ratio was 0.10. Conclusion. General surgery residents have the competence to perform accurate E-FAST scans. The hand-held ultrasound device is an effective diagnostic tool for trauma and acute care surgery patients.

Introducción. La evaluación enfocada extendida con ecografía en trauma (E-FAST, extended focused assessment with sonography for trauma) puede realizarse con entrenamiento mínimo y lograr resultados ideales. Su fácil transporte permite usarla en entornos austeros, como el Caribe colombiano, donde muchos centros no disponen de servicio radiológico las 24 horas. El objetivo de este estudio fue determinar el rendimiento del uso de E-FAST por residentes de cirugía general de segundo año en la evaluación del paciente con trauma en urgencias. Métodos. Estudio observacional retrospectivo que evaluó el rendimiento diagnóstico de E-FAST con Butterfly IQ, en pacientes con trauma toracoabdominal que acudieron a un centro de referencia del Caribe colombiano, entre noviembre de 2021 y julio de 2022. Se evaluaron sensibilidad, especificidad, valores predictivos positivo y negativo, comparando la descripción de la ecografía con los hallazgos intraoperatorios o imagenología convencional. Resultados. Se incluyeron un total de 46 pacientes, con una media de edad de 31,2 ± 13,8 años, siendo el 87,4 % (n=39) hombres. El principal mecanismo de trauma fue penetrante (n=32; 69,5 %). Se encontró que el 80,4 % (n=37) de los pacientes tuvo resultado E-FAST positivo, y que, de estos, el 97 % (n=35) tuvo un hallazgo positivo intraoperatorio. Se calculó una sensibilidad de 92,1 %, especificidad de 75 %, valor predictivo positivo de 94,6 % y negativo de 66,6 %; la razón de verosimilitud positiva fue de 3,68 y la negativa de 0,10. Conclusión. Los residentes de cirugía general están capacitados para realizar exploraciones E-FAST precisas. El ecógrafo portátil es una herramienta de diagnóstico eficaz para pacientes traumatizados.

COVID-19 Provider Relief Fund Payments Were Appropriately Targeted And Did Not Boost Selected Hospitals' Profits.

To help mitigate the COVID-19 pandemic's financial effects on health care providers, Congress allocated $178 billion to the Provider Relief Fund (PRF) beginning in 2020. Using monthly data from January 2018 through June 2022 from a nationally representative sample of US hospitals, we used a difference-in-differences approach to examine whether hospitals receiving medium and high PRF support intensity had higher average monthly operating margins (measured separately with and without accounting for PRF payments) than those that received low PRF support intensity. We also assessed the impact of PRF payments by hospitals' prepandemic financial vulnerability status, measured by whether their average operating margins in 2018 and 2019 were above or below the national median. Our findings indicate that PRF distributions to hospitals were appropriately targeted and did not make some hospitals significantly more profitable than others; rather, PRF payments helped offset financial losses associated with the pandemic. The effects of PRF support intensity were concentrated among hospitals that were financially vulnerable before the pandemic and thus in need of support to remain financially viable during the crisis.

The Volume and Cost of Quality Metric Reporting.

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Analysis of Hospital Operating Margins and Provision of Safety Net Services.

Importance: Safety net hospitals (SNH) provide many community services. The cost of providing these services is unknown. Objective: To determine what safety net criteria are associated with differences in hospital operating margin. Design, Setting, and Participants: This cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports. Exposures: Five domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index. Main Outcomes and Measures: Operating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates. Results: A total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin. Conclusions and Relevance: In this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.

The Medicare IPPS 40 Years Later: Lessons Learned and What to Do Next.

The 1983 implementation of the Medicare Inpatient Prospective Payment System (IPPS) was successful in controlling Medicare inpatient costs because it was designed as a clinically credible management tool that facilitated real behavior change and performance improvement. The next phase of IPPS should expand the inpatient payment bundle to a hospital episode-of-care performance bundle that explicitly links episode cost and quality. A uniform, comparable, and transparent episode performance bundle that highlights the tradeoffs between episode cost and quality can expand the incentives to control costs and provide hospitals the management information to improve performance.

Comparison of the Financial and Operational Characteristics of For-Profit and Nonprofit Hospitals Receiving Federal Graduate Medical Education Payments, 2011-2020.

This study compares graduate medical education (GME) payments between nonprofit and for-profit hospitals between 2011 and 2020 to assess how hospitals value GME.