IMPORTANCE: In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program ...included reducing unnecessary hospital utilization and encouraging greater use of primary care. OBJECTIVE: To compare changes in hospital and primary care use through the first 2 years of Maryland’s hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas. DESIGN, SETTING, AND PARTICIPANTS: We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption). MAIN OUTCOMES AND MEASURES: Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay). RESULTS: We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean SD age, 72.3 12.2 years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean SD age, 71.7 12.5 years). Assuming parallel trends, we estimated a differential change in Maryland of −0.47 annual hospital stays per 100 beneficiaries (95% CI, −1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of −1.24 stays per 100 beneficiaries (95% CI, −2.46 to −0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (−0.8 visits/100 beneficiaries; 95% CI, −10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland’s program. CONCLUSIONS AND RELEVANCE: We did not find consistent evidence that Maryland’s hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.
As financial pressures on hospitals increase because of changing reimbursement structures and heightened focus on quality and value, the association between patient safety performance and financial ...outcomes remains unclear.
The purpose of this study is to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance.
Using multinomial logistic regression, we analyzed data from the spring 2014 Leapfrog Hospital Safety Score and the 2014 American Hospital Association to determine the association between Leapfrog Hospital Safety Score performance and three dimensions of organizational profitability: operating margin, net patient revenue, and operating income.
Our findings suggest that improved hospital safety scores are associated with a relative risk of being in the top versus bottom quartile of financial performance: 5.41 times greater (p < .001) for operating margin, 10.98 times greater (p < .001) for net patient revenue, and 4.03 times greater (p < .001) for operating income.
Our findings suggest that improved patient safety performance, as evaluated within the Leapfrog Hospital Safety Score, is associated with improved financial performance at the hospital level. Targeted focus on patient safety may allow hospitals to improve financial performance, maximize scarce resources, and generate additional capital to continue to positively evolve care.
OBJECTIVE:To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to ...implementing such a program.
METHODS:This was a qualitative study. We interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. Data were analyzed using directed qualitative content analysis principles. We used the Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. We compared this guide to hospitalsʼ implementation experiences.
RESULTS:At the completion of the study, LARC was available for immediate postpartum placement at 7 of 10 study hospitals. Participants identified common themes for the implementation experienceteam member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Participants expressed a need for anticipatory guidance throughout the process. Key first steps to immediate postpartum LARC program implementation were identifying project champions, creating an implementation team that included all relevant departments, obtaining financial reassurance, and ensuring hospital administration awareness of the project. Potential barriers included lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork. Although the implementation guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not all hospitals required every step to succeed.
CONCLUSION:Hospital teams report that implementing immediate postpartum LARC programs involves multiple departments and a number of important steps to consider. A stage-based approach to implementation, and a standardized guide detailing these steps, may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting.
Abstract Objectives The aim of our paper is to analyse the effect of the so-called performance volume limit (PVL) financing method on acute hospital care. Data and methods The data were derived from ...the nationwide administrative dataset of the National Health Insurance Fund Administration (OEP) covering the period 2003–2008. We analysed the trends in the DRG cost-weights, number of cases, case-mix, and average length of stay. We calculated the average annual reimbursement rate per DRG cost-weight with and without the application of PVL degression according to the hospital type and medical professions. Results Our results showed that although the national case mix (i.e., the sum of all of the DRG cost-weights produced in one year) did not change between 2003–2006, the trend of the annual number of cases increased, and the average length of stay decreased. During 2007–2008, a significant decline was found in each indicator. The introduction of the PVL resulted in a health insurance budget saving of 1.9% in 2004, 2.6% in 2005, 3.4% in 2006, 5.6% in 2007, and 3.2% in 2008. We found the lowest reimbursement rate per DRG cost-weight at the university medical schools (HUF 138,200 or € 550) and children's hospitals (HUF 132,547 or € 528), whereas the highest was at the county hospitals (HUF 143,451 or € 571) and city hospitals (HUF 142, 082 or € 565). Conclusions The implementation of the PVL reduced the acute care hospital activity and reimbursement. The effect of the PVL was different on the different types of hospitals, and it had a serious disadvantageous effect on the university medical schools and children's hospitals.
The financial viability of rural hospitals has been a matter of serious concern, with ongoing closures affecting rural residents' access to medical services. We examined the financial viability of ...1,004 US rural hospitals that had consistent rural status in 2011-17. The median overall profit margin improved for nonprofit critical access hospitals (from 2.5 percent to 3.2 percent) but declined for other hospitals (from 3.0 percent to 2.6 percent for nonprofit non-critical access hospitals, from 3.2 percent to 0.4 percent for for-profit critical access hospitals, and from 5.7 percent to 1.6 percent for for-profit non-critical access hospitals). Occupancy rate and charge markup were positively associated with overall margins: In 2017 hospitals with low versus high occupancy rates had median overall profit margins of 0.1 percent versus 4.7 percent, and hospitals with low versus high charge markups had median overall margins of 1.8 percent versus 3.5 percent. Rural hospital financial viability deteriorated in states that did not expand eligibility for Medicaid and was lower in the South. Rural hospitals that closed during the study period had a median overall profit margin of -3.2 percent in their final year before closure. Policy makers should compare the incremental cost of providing essential services between hospitals and other settings to balance access and efficiency.
IMPORTANCE The effect of surgical complications on hospital finances is unclear. OBJECTIVE To determine the relationship between major surgical complications and per-encounter hospital costs and ...revenues by payer type. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of administrative data for all inpatient surgical discharges during 2010 from a nonprofit 12-hospital system in the southern United States. Discharges were categorized by principal procedure and occurrence of 1 or more postsurgical complications, using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes. Nine common surgical procedures and 10 major complications across 4 payer types were analyzed. Hospital costs and revenue at discharge were obtained from hospital accounting systems and classified by payer type. MAIN OUTCOMES AND MEASURES Hospital costs, revenues, and contribution margin (defined as revenue minus variable expenses) were compared for patients with and without surgical complications according to payer type. RESULTS Of 34 256 surgical discharges, 1820 patients (5.3%; 95% CI, 4.4%-6.4%) experienced 1 or more postsurgical complications. Compared with absence of complications, complications were associated with a $39 017 (95% CI, $20 069-$50 394; P < .001) higher contribution margin per patient with private insurance ($55 953 vs $16 936) and a $1749 (95% CI, $976-$3287; P < .001) higher contribution margin per patient with Medicare ($3629 vs $1880). For this hospital system in which private insurers covered 40% of patients (13 544), Medicare covered 45% (15 406), Medicaid covered 4% (1336), and self-payment covered 6% (2202), occurrence of complications was associated with an $8084 (95% CI, $4903-$9740; P < .001) higher contribution margin per patient ($15 726 vs $7642) and with a $7435 lower per-patient total margin (95% CI, $5103-$10 507; P < .001) ($1013 vs −$6422). CONCLUSIONS AND RELEVANCE In this hospital system, the occurrence of postsurgical complications was associated with a higher per-encounter hospital contribution margin for patients covered by Medicare and private insurance but a lower one for patients covered by Medicaid and who self-paid. Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.
To evaluate the impact that an innovative automated ultrasound (US) work flow, which allows for bedside performance of examination documentation and order placement, has on point-of-care US billing ...compared to ordering US examinations through an electronic medical record.
We conducted a retrospective review of point-of-care US billing data (March 2014-February 2016) for adult and pediatric emergency departments with an emergency medicine residency and a US fellowship. An innovative work flow with the ability to automate US billing and selectively transfer the images and reports for patient care examinations to an electronic medical record and picture archiving and communication system using the QPath US work flow solution (Telexy Healthcare, Maple Ridge, British Columbia, Canada) was implemented. The total number of examinations billed and percent increase in technical and professional revenue, excluding examinations performed by US fellows, before and after implementation of the automated work flow innovation were determined.
After implementation of our automated US work flow process, the number of patient care US examinations billed increased significantly due to completing documentation and immediate billing determination at the bedside. The increase in percent billing relative to total examinations was noted in both technical (32% to 61%; P < .0001) and professional (37% to 65%; P < .0001) billing components. In addition, there was a net increase in technical and professional fee revenue to 96% and 78%, respectively.
The implementation of an innovative automated work flow to include bedside point-of-care US documentation, order placement, and the automated transfer of images and reports led to a significant increase in US billing revenue, documentation, and compliance.
Currently, the green procurement activities of private hospitals in Taiwan follow the self-built green electronic-procurement (e-procurement) system. This requires professional personnel to take the ...time to regularly update the green specification and software and hardware of the e-procurement system, and the information system maintenance cost is high. In the case of a green e-procurement system crash, the efficiency of green procurement activities for hospitals is affected. If the green e-procurement can be moved to a convenient and trusty cloud computing model, this will enhance the efficiency of procurement activities and reduce the information maintenance cost for private hospitals. However, implementing a cloud model is an issue of technology innovation application and the technology-organization-environment (TOE) framework has been widely applied as the theoretical framework in technology innovation application. In addition, finding the weight of factors is a multi-criteria decision-making (MCDM) issue. Therefore, the present study first collected factors influencing implementation of the cloud mode together with the TOE as the theoretical framework, by reviewing the literature. Therefore, an expert questionnaire was designed and distributed to top managers of 20 private hospitals in southern Taiwan. The fuzzy analysis hierarchical process (FAHP), which is a MCDM tool, finds the weights of the factors influencing private hospitals in southern Taiwan when they implement a cloud green e-procurement system. The research results can enable private hospitals to successfully implement a green e-procurement system through a cloud model by optimizing resource allocation according to the weight of each factor. In addition, the results of this research can help cloud service providers of green e-procurement understand users' needs and develop relevant cloud solutions and marketing strategies.
Hospitalists, or physicians specializing in hospital-based practice, have grown significantly since they were first introduced in the United States in the mid-1990s. Prior studies on the impact of ...hospitalists have focused on costs and length of stay. However, there is dearth of research exploring the relationship between hospitals' use of hospitalists and organizational performance.
Using a national longitudinal sample of acute care hospitals operating in the United States between 2007 and 2014, this study explores the impact of hospitalists staffing intensity on hospitals' financial performance.
Data sources for this study included the American Hospital Association Annual Survey, the Area Health Resources File, and the Centers for Medicare & Medicaid Services' costs reports and Case Mix Index files. Data were analyzed using a panel design with facility and year fixed effects regression.
Results showed that hospitals that switched from not using hospitalists to using a high hospitalist staffing intensity had both increased patient revenues and higher operating costs per adjusted patient day. However, the higher operating costs from high hospitalist staffing intensity were offset by increased patient revenues, resulting in a marginally significant increase in operating profitability (p < .1).
These findings suggest that the rise in the use of hospitalists may be fueled by financial incentives such as increased revenues and profitability in addition to other drivers of adoption.
PDF
