Inadequate hospital reimbursement for victims of motor vehicle crashes due to health reform legislation

Rates of insurance for injured patients before and after health care reform in Massachusetts: a possible case of double jeopardy

OBJECTIVES

We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.

METHODS

We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004-2005) and after (2009-2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.

RESULTS

Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.

CONCLUSIONS

Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in "double jeopardy" of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.

A financial analysis of operative facial fracture management

BACKGROUND

The financial impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of patients undergoing operative facial fracture management at a single academic medical center and the financial impact on the health system.

METHODS

The records of 202 patients who underwent operative facial fracture management over a 3-year period (2003 to 2005) were analyzed. All physician (professional) and hospital charges related to fracture management were included. Professional charges were subdivided by specialty and by payer type; hospital charges included operating room, recovery room, intensive care unit, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs. For comparison, similar data were obtained for the general plastic surgery population and for orthopedic surgery patients.

RESULTS

The sum of all professional charges billed was $2,478,234 (average, $12,268 per patient). Collections for these professional services totaled $675,434, yielding an overall reimbursement rate of 27 percent. Reimbursement rates ranged from 38 percent for critical care physicians to 24 percent for surgery and neuroradiology. The highest collection rates occurred in children covered by the State Children's Health Insurance Program and in prison inmates (53 percent and 99 percent, respectively). The lowest collection rates were obtained from uninsured patients (10 percent total billing over collections). Total hospital charges were $18,120,027 (average, $89,703 per patient); the total collections were $2,770,115 (15 percent reimbursement rate).

CONCLUSIONS

This study provides a descriptive financial analysis of operative facial fracture management. The unfavorable financial circumstances associated with facial trauma care may present a challenge to academic medical centers and plastic surgeons.

Discharge Rounds in the 80-Hour Workweek: Importance of the Trauma Nurse Practitioner

BACKGROUND

Daily multidisciplinary discharge rounds have been shown to decrease length of stay (LOS), increase patient volumes, and virtually eliminates "bypass" (inability to accept admissions). Originally, these were attended by senior house staff from each trauma team. Implementation of the 80-hour workweek precluded house staff participation, raising concerns that these rounds would loss their benefits. Certified nurse practitioners (CRNPs) were added to the trauma teams to assist in patient care and represent the team on discharge rounds, replacing the fellows. We hypothesized that this would offset any potential negative effects.

METHODS

A senior trauma physician leads discharge rounds, focusing on each patient's plan of care. Rounds cover 90 inpatient beds and last approximately 60 minutes. CRNPs from each trauma team, orthopedics, and neurosurgery as well as the teams' discharge planner, hospital bed manager, unit nursing staff, and physical, occupational, and speech therapists participate in discharge rounds.

RESULTS

The results are stratified by time period: June 1998 to May 1999 is before discharge rounds, June 1999 to May 2001 is during the house staff period, and June 2001 to May 2004 is when CRNPs replaced fellows and residents. During the 5-year period, 1999 to 2004, daily discharge rounds maintained their efficacy. We have increased admissions, whereas LOS has remained the same. Admissions of greater than 24 hours have increased, whereas average injury severity score has statistically remained the same. Bypass has virtually been eliminated.

CONCLUSIONS

Adding CRNPs to discharge rounds has allowed us to have the continued benefits of decreased LOS and increased patient volume. Bypass remains rare. CRNPs can effectively replace some house staff functions.

Maximizing Reimbursement From Trauma Response Fees (UB-92: 68X) ??? Lessons Learned from a Hospital Comparison

BACKGROUND

The trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers' performance in collecting this fee help define methodologies that can enhance reimbursement.

METHODS

Our trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center.

RESULTS

Out of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars)

CONCLUSIONS

Enhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.

[DRG reimbursement for multiple trauma patients -- a comparison with the comprehensive hospital costs using the German trauma registry]

The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the German Trauma Society developed a calculating algorithm to estimate the comprehensive hospital costs for every patient in the German trauma registry. The aim of this study was to compare these costs with the reimbursement according the the G-DRG's for a standardized population of polytrauma patients.

MATERIAL AND METHODS

For polytrauma patients treated at Hannover Medical School in 2000 and 2001 the reimbursement according to the G-DRG's was calculated using a base value of 2900 euro. In the same patients the total cost of inpatient treatment was calculated according to the algorithm developed by the polytrauma working group of the German Trauma Society. The difference between these values represents the economic result. This was calculated as an overall result, but also for specific subgroups of patients (injury severity, mortality, G-DRG grouping).

RESULTS

Datasets of 103 polytrauma patients were included. The following G-DRG's were most frequently occuring: A06Z (n=41), A07Z (n=16), W01Z (n=13). All other G-DRG's were documented less than 3 times. The mean reimbursement according to the G-DRG was 21.380+/-12.300 euro for a polytrauma patient. However, the mean hospital cost accounted to 34.274+/-22.501 euro, which resulted in a mean deficit of 12.893+/-15.534 euro. Analysis of subgroups revealed, that an ISS of more than 35 points, patients with a prolonged hospital stay and patients of the G-DRG group A06Z show a particularly negative result.

CONCLUSION

The comprehensive hospital costs for treating polytrauma patients are on average 12.893 euro higher than the reimbursement according the G-DRG's. For hospitals to be fully reimbursed G-DRG values have to be reconfigured according to the German health care system. Thus, inclusion criteria to specific G-DRG have to be changed and a specific G-DRG group for very severely injured patients needs to be established.

Daily multidisciplinary rounds shorten length of stay for trauma patients

PURPOSE

Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution's training mission. We hypothesized that daily multidisciplinary "discharge rounds" would improve patient flow and increase readiness.

METHODS

A senior trauma center physician leads discharge rounds, focusing on each patient's plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit's discharge planner; the unit nursing staff; and physical, occupational, and speech therapists.

RESULTS

Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. "Bypass" status-inability to accept admissions-has been virtually eliminated. This effect has been sustained.

CONCLUSION

By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.

A prospective cost evaluation related to allogeneic haemopoietic stem cell transplantation including pretransplant procedures, transplantation and 1 year follow-up procedures

The Norwegian Ministry of Health and Social Affairs recently introduced activity-based financing for hospitals partly based on diagnosis-related groups (DRG). We soon observed that there seemed to be a considerable discrepancy between the reimbursement amount and the real cost of allogeneic haemopoietic stem cell transplantation. It was therefore decided to undertake a prospective micro-cost analysis to define a more realistic reimbursement. To identify real costs, we undertook a registration of pre-transplant procedures, transplantation and 1 year follow-up costs, including harvesting, personnel costs, clinical and laboratory procedures, together with blood products and drugs related to patients and donors. These data were compared to hospital DRG reimbursement. This information was registered for 17 consecutive patients, with a mean age 40 years (range 17-58 years). Ten patients had chronic myeloid leukaemia, three had acute lymphatic leukaemia, two had acute myeloid leukaemia and two had myelodysplastic syndrome. The data analysis showed a mean cost of US$ 106825 (NOK 901982), (range US$ 42376-362430). The average actual hospital revenue (50% DRG reimbursement + income related to length of stay + special procedure funding) was US$ 36404 (range US$ 26228-55998). Activity-based financing as applied in Norway, under-compensates hospital costs for allogeneic bone marrow transplantation. The government should make realistic estimates of real costs before introducing financial reforms in the health care system.