COVID-19 and the Financial Health of US Hospitals Khullar, Dhruv; Bond, Amelia M; Schpero, William L
JAMA : the journal of the American Medical Association,
06/2020, Volume:
323, Issue:
21
Journal Article
Peer reviewed
Open access
This Viewpoint reviews the revenue sources and financial liquidity of nonfederal US general hospitals to estimate the economic effects pandemic-related reductions in elective procedures and ...outpatient revenues might have, and argues for targeted government financial support for smaller, independent, and more rural institutions.
Strained hospital capacity is associated with adverse patient outcomes. Anecdotal evidence suggests that during the COVID-19 pandemic in the US, some hospitals experienced capacity constraints while ...others in the same market had surplus capacity, a phenomenon known as "load imbalance." Our study evaluated the prevalence of intensive care unit load imbalance and the characteristics of hospitals most likely to be over capacity while other nearby hospitals were under capacity. Of the 290 hospital referral regions (HRRs) analyzed, 154 (53.1 percent) experienced load imbalance during the study period. HRRs experiencing the most imbalance had higher proportions of Black residents. Hospitals with the highest Medicaid patient shares and Black Medicare patient shares were significantly more likely to be over capacity, while other hospitals in their market were under capacity. Our findings highlight that hospital load imbalance was common during the COVID-19 pandemic. Policies to coordinate transfers may decrease strain during periods of high demand and ease the burden on hospitals that serve a higher proportion of patients from racial minority groups.
Coverage of the “routine costs” associated with clinical trial participation will soon be guaranteed for Medicaid beneficiaries for the first time, which could help reduce inequities that compromise ...both the scientific process and access to new therapeutics.
This Viewpoint discusses the importance of researcher access to federal health care data following a CMS decision to limit the use of physical data and proposes solutions to maintain access and ...security.
Background
Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of ...Internal Medicine Foundation’s Choosing Wisely initiative.
Objective
To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level.
Design
Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services.
Patients
Fee-for-service Medicare beneficiaries over age 65.
Main Measures
Prevalence of selected Choosing Wisely low-value services.
Key Results
The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries.
Conclusions
Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Little is known about how Medicaid disproportionate share hospital payments, which are intended to support hospitals that serve low-income patients, are allocated or whether allocation patterns have ...changed over time. We employed alternative definitions of
, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states. The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015. The majority of payments went to hospitals with Medicaid shares above the state-specific median (89.1 percent), hospitals with uncompensated care shares above the state-specific median (60.6 percent), or hospitals deemed as disproportionate share per statutory definitions (64.6 percent). However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them. These findings suggest that although the majority of the payments were targeted to hospitals serving low-income patients, opportunities exist to better align allocation with statutory goals and intent or to revise applicable statute.
IMPORTANCE: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance ...accurately captures the quality of care they provide. OBJECTIVE: To examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. EXPOSURES: MIPS score. MAIN OUTCOMES AND MEASURES: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. RESULTS: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, −7.1 percentage points 95% CI, −8.0 to −6.2; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, −4.8 percentage points 95% CI, −5.4 to −4.2; P < .001), and mammography screening (58.2% vs 70.4%; difference, −12.2 percentage points 95% CI, −13.1 to −11.4; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points 95% CI, 0.0 to 2.5; P = .045 and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points 95% CI, 0.3 to 1.5; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, −8.9 95% CI, −13.7 to −4.1; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 95% CI, 24.8 to 35.7; P < .001), and did not have significantly different performance on 4 ambulatory care–sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. CONCLUSIONS AND RELEVANCE: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.
States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that ...require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.
Recent research has shown that concern about the apprehension and deportation of undocumented immigrants can affect how members of their households who are eligible for public benefits choose to ...participate in public programs. The extent to which this "chilling effect" broadly affects adults' Medicaid enrollment nationally remains unclear, in part because of the difficulty of isolating undocumented immigrants in survey data. In this study we identified households that likely included undocumented immigrants and then examined whether gains in health care coverage due to the expansion of Medicaid eligibility under the Affordable Care Act (ACA) were dampened for eligible people living in households with mixed immigration status. We found no significant differences in coverage gains for people in mixed- relative to non-mixed-status households in expansion states. Coverage gains were significantly lower, however, for people in mixed-status households relative to those in non-mixed-status households in nonexpansion states. These findings suggest that household immigration status may have dampened the "woodwork effect," whereby the ACA enhanced knowledge about program availability, in turn increasing Medicaid enrollment in nonexpansion states among people previously eligible for the program but not enrolled in it.
This Viewpoint discusses how revisiting the design and implementation of the disproportionate share hospital program represents a key policy lever for improving health equity in the US.
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