Uncompensated Care Provided by Emergency Physicians in Florida Emergency Departments

Impact of slack resources on healthcare costs in tertiary and secondary hospitals: a panel data study of public hospitals in Beijing from 2015 to 2019

OBJECTIVE

This study aims to explore the relationship between slack resources and cost consumption index in tertiary and secondary hospitals and to provide targeted healthcare resource utilisation recommendations for tertiary and secondary hospital managers.

DESIGN

This is a panel data study of 51 public hospitals in Beijing from 2015 to 2019.

SETTING

Tertiary and secondary public hospitals in Beijing. Data envelope analysis was used to calculate the slack resources. Regression models were used to explore the relationship between slack resources and healthcare costs.

PARTICIPANTS

A total of 255 observations were collected from 33 tertiary hospitals and 18 secondary hospitals.

OUTCOME MEASURES

Slack resources and healthcare costs in tertiary and secondary public hospitals in Beijing from 2015 to 2019. Linear or curve relationship between slack resources and healthcare costs in tertiary and secondary hospitals.

RESULTS

The cost of healthcare in tertiary hospitals has always been higher than in secondary hospitals, and the slack resources in secondary hospitals have always been worse than in tertiary hospitals. For tertiary hospitals, the cubic coefficient of slack resources is significant (β=-12.914, p<0.01) and the R² of cubic regression is increased compared with linear and quadratic regression models, so there is a transposed S-shaped relationship between slack resources and cost consumption index. For secondary hospitals, only the first-order coefficient of slack resources in the linear regression was significant (β=0.179, p<0.05), so slack resources in secondary hospitals were positively related to the cost consumption index.

CONCLUSIONS

This study shows that slack resources' impact on healthcare costs differs in tertiary and secondary public hospitals. For tertiary hospitals, slack should be kept within a reasonable range to control excessive growth in healthcare costs. In secondary hospitals, keeping too many slack resources is not ideal, so managers should adopt strategies to improve competitiveness and service transformation.

Emergency department imaging: uncompensated services rendered by radiologists nationwide

PURPOSE

The aim of this study was to examine characteristics of uncompensated services rendered by radiologists to emergency department (ED) patients.

METHODS

Using deidentified billing claims for 2,935 radiologists from 40 states from 2009 through 2012, 18,475,491 services rendered to ED patients were identified. Analysis focused on the 133 of 830 procedure codes that comprised 99.0% (18,296,734) of all rendered services. The frequency, magnitude, and other characteristics of uncompensated (defined as zero payment) radiologist services were analyzed. National 2012 Medicare Physician Fee Schedule amounts were used to estimate service dollar values.

RESULTS

Of 2,935 radiologists, 2,835 (96.6%) provided uncompensated care to ED patients, averaging $2,584 in professional services per physician per service month. Radiologists received no compensation at all for 28.4% of services (5,194,732 of 18,296,734). Just 8 procedure codes describing various chest, foot, and ankle radiographic and brain, abdominal and pelvic, and cervical spine CT examinations accounted for 51.0% of all imaging services rendered to ED patients. CT represented 31.2% of all services but accounted for 64.8% of uncompensated dollars. Although the uninsured received only 15.8% of all services, they accounted for 52.3% of all uncompensated services (2,714,506).

CONCLUSION

More than 28% of services rendered by radiologists to ED patients are uncompensated, corresponding to $2,584 per month per physician. That frequency and magnitude could have patient access implications.

The effect of the Massachusetts reform on health care utilization

The 2006 Massachusetts health care reform expanded insurance coverage in the state to near-universal levels. As the uninsured gained coverage, their out-of-pocket costs of medical care fell, inducing them to seek more care. This paper analyzes the effect of the reform on reported health care utilization and outcomes by both synthesizing the existing research on the Massachusetts health care reform and providing new evidence using the National Health Interview Survey. The results show evidence that the Massachusetts reform increased residents' use of health care services including primary and preventive care, reduced reliance on the hospital emergency room as a usual source of care, and improved self-reported health.

The influence of payer mix on electronic prescribing by physicians

BACKGROUND

Limited studies have examined electronic prescribing (e-prescribing) adoption in physician office practices. Specifically, none have explored the influence of payer mix on e-prescribing adoption among physicians.

PURPOSE

This study examines the impact of practice composition of Medicare, Medicaid, and private insurance on e-prescribing adoption among physicians.

METHODOLOGY/APPROACH

Logistic regression was used to analyze data collected from a large-scale information technology-related survey of Florida physicians.

FINDINGS

After controlling for practice and physician characteristics, physicians with the highest (odds ratio = 1.67, 95% confidence interval = 1.01-2.78) and above-average (odds ratio [OR] = 1.83, 95% confidence interval = 1.04-3.22) volume of Medicare patients were significantly more likely to e-prescribe as compared with those in the low-volume category. No differences in adoption were found across all Medicaid and private insurance practice composition categories.

PRACTICE IMPLICATIONS

Our findings support the notion that direct incentives, such as those in the Medicare Modernization Act of 2003, may influence physician adoption of e-prescribing.

The crisis in United States hospital emergency services

PURPOSE

Emergency services are critical for high-quality healthcare service provision to support acute illness, trauma and disaster response. The greater availability of emergency services decreases waiting time, improves clinical outcomes and enhances local community well being. This study aims to assess United States (U.S.) acute care hospital staffs ability to provide emergency medical services by evaluating the number of emergency departments and trauma centers.

DESIGN/METHODOLOGY/APPROACH

Data were obtained from the 2003 and 2007 American Hospital Association (AHA) annual surveys, which included over 5000 US hospitals and provided extensive information on their infrastructure and healthcare capabilities.

FINDINGS

U.S. acute care hospital numbers decreased by 59 or 1.1 percent from 2003 to 2007. Similarly, U.S. emergency rooms and trauma centers declined by 125, or 3 percent. The results indicate that US hospital staffs ability to respond to traumatic injury and disasters has declined. Therefore, US hospital managers need to increase their investment in emergency department beds as well as provide state-of-the-art clinical technology to improve emergency service quality. These investments, when linked to other clinical information systems and the electronic medical record, support further healthcare quality improvement.

RESEARCH LIMITATIONS/IMPLICATIONS

This research uses the AHA annual surveys,which represent self-reported data by individual hospital staff. However, the AHA expendssignificant resources to validate reported information and the annual survey data are widely used for hospital research.

PRACTICAL IMPLICATIONS

The declining US emergency rooms and trauma centers have negative implications for patients needing emergency services. More importantly, this research has significant policy implications because it documents a decline in the US emergency healthcare service infrastructure.

ORIGINALITY/VALUE

This article has important information on US emergency service availability in the hospital industry.

Regionalization of surgical services in central Florida: the next step in acute care surgery

BACKGROUND

There is a national loss of access to surgeons for emergencies. Contributing factors include reduced numbers of practicing general surgeons, superspecialization, reimbursement issues, emphasis on work and life balance, and medical liability. Regionalizing acute care surgery (ACS), as exists for trauma care, represents a potential solution. The purpose of this study is to assess the financial and resources impact of transferring all nontrauma ACS cases from a community hospital (CH) to a trauma center (TC).

METHODS

We performed a case mix and financial analysis of patient records with ACS for a rural CH located near an urban Level I TC. ACS patients were analyzed for diagnosis, insurance status, procedures, and length of stay. We estimated physician reimbursement based on evaluation and management codes and procedural CPT codes. Hospital revenues were based on regional diagnosis-related group rates. All third-party remuneration was set at published Medicare rates; self-pay was set at nil.

RESULTS

Nine hundred ninety patients were treated in the CH emergency department with 188 potential surgical diseases. ACS was necessary in 62 cases; 25.4% were uninsured. Extrapolated to 12 months, 248 patients would generate new TC physician revenue of >$155,000 and hospital profits of >$1.5 million. CH savings for call pay and other variable costs are >$100,000. TC operating room volume would only increase by 1%.

CONCLUSION

Regionalization of ACS to TCs is a viable option from a business perspective. Access to care is preserved during an approaching crisis in emergency general surgical coverage. The referring hospital is relieved of an unfavorable payer mix and surgeon call problems. The TC receives a new revenue stream with limited impact on resources by absorbing these patients under its fixed costs, saving the CH variable costs.

One method for financing America's uninsured

The United States has 45 million individuals who lack health insurance, causing them to experience higher morbidity and mortality rates. One method for funding the uninsured includes creating an annuity (federally funded at $1,000 per year for the first 5 years of one's life) for each newborn. When the annuity matures, at the age of 45 years, the individual will have a large health care fund. When coupled with options such as familial vesting, within a few generations, these annuities have the capacity to ultimately provide health care coverage from birth through old age.

Impact of Medicaid cutbacks on emergency department use: the Oregon experience

STUDY OBJECTIVE

Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use.

METHODS

In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity.

RESULTS

After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62).

CONCLUSION

Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999-2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to "stabilize" a patient suffering from an "emergency medical condition" before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users' characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.

The effect of payer mix on the adoption of information technologies by hospitals

BACKGROUND

Numerous studies have examined the relationship between organization characteristics and hospital adoption of information technology (IT). However, no known study has examined whether patient characteristics of those treated at a given hospital influences the decision to adopt IT.

PURPOSE

The present study combines primary and secondary data to examine the effect of payer mix (the combination of payers that make up a given hospital's patient discharges) on IT adoption in hospitals.

METHODS

Survey data from Florida hospitals were combined with the state's hospital discharge database. Multiple regression analyses were used to analyze the data.

RESULTS

When examining Medicare, Medicaid, traditional commercial insurance, and managed-care plans, only an increase of managed-care patients, as a percentage of hospital discharges, was associated with a significant increased likelihood to adopt clinical and administrative IT applications by hospitals.

PRACTICE IMPLICATIONS

Our results suggest that increasing cost pressures associated with managed-care environments are driving hospitals' adoption of clinical and administrative IT systems as such adoption is expected to improve hospital efficiency and lower costs. Given that such cost pressures are also emergent in Medicare, Medicaid, and traditional third-party payment environments, an opportunity exists for these parties to motivate hospital IT adoption as a means for cost reduction.