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.

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.

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.

[Hospital Profits: Ethical Aspects at the Interface Between Medicine and Economics]

Hospital profits and economization trends are increasingly becoming the focus of discussions on improving health care systems. Profit-based approaches to generate hospital returns have an ethical dimension, because patient well-being must remain the primary concern. A needs-oriented economic approach without the dominance of primary profit targets should become an overarching framework for the hospital sector.

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.

Structural Racial Disparities in the Allocation of Disproportionate Share Hospital Payments

This cross-sectional study examines the allocation of Medicare and Medicaid Disproportionate Share Hospital payments by race.

Performance Evaluation of Hospital Economic Management with the Clustering Algorithm Oriented towards Electronic Health Management

In order to study the clustering algorithm based on density grid, the performance evaluation index system of hospital economic management under the application of electronic health management system is constructed. Firstly, this work designs the basic architecture of electronic health management system, classifies and screens the process of index system of electronic health management system, compares the clustering algorithm based on density grid with the simple clustering algorithm based on density or grid, and then applies it to the performance evaluation index system of hospital economic management. According to the principle of Mitchell scoring method, the expert questionnaire of hospital economic management performance evaluation index system was designed, and Delphi method was used to evaluate the candidate indexes from the three dimensions of right, legitimacy, and urgency. The results show that, compared with simple network clustering algorithm and density clustering algorithm, the clustering algorithm based on density network produces higher purity (94% VS 73% VS 67%) and lower entropy (0.9 VS 1.4 VS 1.54), which effectively saves memory consumption, and the difference is statistically significant (P < 0.05). The core indicators with scores above 4.5 in both dimensions include budget revenue implementation rate, budget expenditure implementation rate, implementation rate of special financial appropriation, asset-liability ratio, hospitalization income cost rate, medical insurance settlement rate, average cost of discharged patients, and drug proportion. The coefficient of variation of the first grade index is between 0.05 and 0.14 and that of the second grade index is between 0.05 and 0.15. Clustering algorithm based on density network has higher purity and lower entropy, which can effectively save memory consumption. The performance evaluation index system of hospital economic management finally determines 6 first-level indexes: budget management, financial fund management, cost management, medical expense management, medical efficiency, medical quality, and 25 second-level indexes.

Celebrating a decade of the minor operations clinic: an approach at a regional New Zealand hospital

BACKGROUND

A minor operations clinic has been providing a "one-stop shop" at our regional New Zealand hospital for the past decade to service management of skin lesions. This study aims to assess demographics, service characteristics, clinical standards and cost-savings from this setup, and to identify areas for improvement and potentially provide a model for other health units.

METHODS

All patients seen between May 2009 and June 2019 were prospectively included. Data includes demographics, waitlist period, referral sources, follow-up destinations, histology including involvement of margins and cost.

RESULTS

A total of 4,926 patients were included, with 6,442 procedures overall. Median age was 72 years old. The main source of referrals was primary care. The majority of patients were returned directly to primary care. Median wait-time was 66 days, and this remained static over the decade. 56.6% of excised lesions yielded malignant histology and 90.1% achieved clear margins. There was a calculated saving of NZ$607.00 per patient with our one-stop shop compared to our previous traditional model. A further calculated saving of NZ$452,028.50 was achieved by diverting complex procedures from requiring operating theatre environments.

CONCLUSIONS

Our model provides successful, streamlined and cost-effective treatment of skin lesions for our community. This model (or aspects of) may be similarly effective in other regional centres.

Year 1 of the Bundled Payments for Care Improvement-Advanced Model

BACKGROUND

The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments.

METHODS

We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix.

RESULTS

A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix.

CONCLUSIONS

The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.).

Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes

BACKGROUND

Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting.

METHOD

Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method.

RESULTS

A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index.

CONCLUSIONS

Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.

Association Between the Proportion of Black Patients Cared for at Hospitals and Financial Penalties Under Value-Based Payment Programs

This study evaluates whether US hospitals with mostly Black patients are more likely than other hospitals to have penalties associated with Centers for Medicare & Medicaid Services (CMS) value-based payment programs.

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program

Importance

The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown.

Objective

To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification.

Design, Setting, and Participants

This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied.

Exposures

Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall.

Main Outcomes and Measures

Penalties in the prestratification vs poststratification schemes.

Results

The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status.

Conclusions and Relevance

This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study

Objectives

Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC).

Methods

We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System.

Results

In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69–9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32–31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals.

Conclusion

The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

Association of State Certificate of Need Regulation With Procedural Volume, Market Share, and Outcomes Among Medicare Beneficiaries

IMPORTANCE

Certificate of need laws provide state-level regulation of health system expenditure. These laws are intended to limit spending and control hospital expansion in order to prevent excess capacity and improve quality of care. Several states have recently introduced legislation to modify or repeal these regulations, as encouraged by executive order 13813, issued in October 2017 by the Trump administration.

OBJECTIVE

To evaluate the difference in markers of hospital activity and quality by state certificate of need status. These markers include hospital procedural volume, hospital market share, county-level procedures per 10 000 persons, and patient-level postoperative outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study involving Medicare beneficiaries aged 65 years or older who underwent 1 of the following 10 procedures from January 1, 2016, through November 30, 2018: total knee or hip arthroplasty, coronary artery bypass grafting, colectomy, ventral hernia repair, lower extremity vascular bypass, lung resection, pancreatic resection, cystectomy, or esophagectomy.

EXPOSURES

State certificate of need regulation status as determined by data from the National Conference of State Legislatures.

MAIN OUTCOMES AND MEASURES

Outcomes of interest included hospital procedural volume; hospital market share (range, 0-1; reflecting 0%-100% of market share); county-level procedures per 10 000 persons; and patient-level postoperative 30-day mortality, surgical site infection, and readmission.

RESULTS

A total of 1 545 952 patients (58.0% women; median age 72 years; interquartile range, 68-77 years) at 3631 hospitals underwent 1 of the 10 operations. Of these patients, 468 236 (30.3%) underwent procedures in the 15 states without certificate of need regulations and 1 077 716 (69.7%) in the 35 states with certificate of need regulations. The total number of procedures ranged between 729 855 total knee arthroplasties (47.21%) and 4558 esophagectomies (0.29%). When comparing states without vs with certificate of need regulations, there were no significant differences in overall hospital procedural volume (median hospital procedure volume, 241 vs 272 operations per hospital for 3 years; absolute difference, 31; 95% CI, -27.64 to 89.64; P = .30). There were no statistically significant differences between states without vs with certificate of need regulations for median hospital market share (median, 28% vs 52%; absolute difference, 24%; 95% CI, -5% to 55%; P = .11); procedure rates per 10 000 Medicare-eligible population (median, 239.23 vs 205.41 operations per Medicare-eligible population in 3 years; absolute difference, 33.82; 95% CI, -84.08 to 16.43; P = .19); or 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission rate (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries who underwent a range of surgical procedures from 2016 through 2018, there were no significant differences in markers of hospital volume or quality between states without vs with certificate of need laws. Policy makers should consider reevaluating whether the current approach to certificate of need regulation is achieving the intended objectives and whether those objectives should be updated.

Plastic surgery procedure unit: A streamlined care model for minor and intermediate procedures: A cost-benefit analysis

INTRODUCTION

The advent of wide-awake local anaesthesia has led to a reduced need for main theatre for trauma and elective plastic procedures. This results in significant cost-benefits for the institution. This study aims to show how a dedicated 7 days/ week plastic surgery procedural (PSP) unit, performing both elective and trauma surgeries, can lead to significant cost-benefits for the institution.

METHODS

Retrospective review of all cases performed in the PSP unit between 1 September and 31 August 2018. We utilised hospital directory admissions data and the hospital's intranet operating theatre system to calculate hospital days saved. Cost analysis was performed using Saolta financial data.

RESULTS

A total of 3058 operations were performed. Of these operations, 2388 cases were elective and 670 were trauma cases. The average waiting time for trauma cases for main operating theatre was 1.4 days, saving a total of 487 hospital days. The total savings associated with hospital bed days were €347,861. The estimated resource savings from performing a procedure in PSP compared with main theatre with regional anaesthesia were €529.00 and €391.00 without regional anaesthesia. The cost saved due to resources was therefore €337,226. The total cost-benefit associated with performing surgeries in PSP including hospital days and resources saved was calculated as €685,087.

CONCLUSION

This study shows the benefit of performing elective and trauma operations in minor procedure units such as PSP. PSP results in a more efficient service, reducing waiting times for surgery, shorter hospital stay, reduced operating cost and an overall significant cost saving.

Association Between State Medicaid Expansion and Emergency Access to Acute Care Hospitals in the United States

IMPORTANCE

State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals.

OBJECTIVE

To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals.

EXPOSURES

State-level Medicaid expansion.

MAIN OUTCOMES AND MEASURES

Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital.

RESULTS

States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [-0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P < .001) and for low-income persons (without expansion: 7.43% to 7.39% [-0.04%]; vs with expansion: 6.25% to 6.15% [-0.10%]; difference-in-differences, 0.06%; 95% CI, 0.05%-0.07%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 421 000 more persons overall and 48 000 more low-income persons would have retained access. States that did not expand Medicaid experienced an increase in the population without access to safety-net hospitals overall (46.91% to 47.70% [0.79%] vs 33.94% to 33.07% [-0.87%]; difference-in-differences, 1.66%; 95% CI, 1.64%-1.66%; P < .001) and for low-income persons (45.28% to 46.14% [0.86%] vs 33.00% to 32.23% [-0.77%]; difference-in-differences, 1.63%; 95% CI, 1.63%-1.67%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 2 242 000 more persons overall and 364 000 more low-income persons would have retained access.

CONCLUSIONS AND RELEVANCE

States that did not expand Medicaid under the Patient Protection and Affordable Care Act were associated with worse emergency access to acute care hospitals compared with states that expanded Medicaid.

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study

Background

The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction.

Methods

Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010–2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics.

Results

At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%).

Interpretation

This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Cost-effectiveness of real-world administration of chemotherapy and add-on Viscum album L. therapy compared to chemotherapy in the treatment of stage IV NSCLC patients

Background

For stage IV lung cancer patients receiving add-on Viscum album L. (VA) treatment an improved overall survival was detected. Information regarding cost-effectiveness (CE) for comparisons between chemotherapy (CTx) and CTx plus additive VA in stage IV lung cancer treatment is limited. The present study assessed the costs and cost-effectiveness of CTx plus VA (V) compared to CTx alone (C) for stage IV non-small cell lung cancer (NSCLC) patients treatment in a hospital in Germany.

Methods

In the observational real-world data study, data from the Network Oncology clinical registry were utilized. Enrolled stage IV lung cancer patients received the respective therapy (C or V) in a certified German Cancer Center. Cost and cost-effectiveness analyses from the hospital’s perspective were investigated on the basis of overall survival (OS) and routine financial controlling data. In addition, the incremental cost-effectiveness ratio (ICER) was calculated. The primary result of the analysis was tested for robustness in a bootstrap-based sensitivity analysis.

Results

118 patients (C: n = 86, V: n = 32) were included in the analysis, mean age 63.8 years, the proportion of male patients was 55.1%. Adjusted hospital’s total mean costs for patients from the C and V group were €16,289, 95%CI: 13,834€-18,744€ (over an adjusted mean OS time of 13.4 months) and €17,992, 95%CI: 13,658–22,326 (over an adjusted mean OS time of 19.1 months), respectively. The costs per additional OS year gained (ICER) with the V-therapy compared to C therapy were €3,586.

Conclusion

The findings of the present study suggest that the combined use of chemotherapy and VA was clinically effective and comparably cost-effective to chemotherapy alone in our analysed patient sample from the hospital’s perspective. Further randomized and prospective cost-effectiveness studies are necessary to complement our findings.

Public Attitudes Regarding Hospitals and Physicians Encouraging Donations From Grateful Patients

IMPORTANCE

Philanthropy is an increasingly important source of support for health care institutions. There is little empirical evidence to inform ethical guidelines.

OBJECTIVE

To assess public attitudes regarding specific practices used by health care institutions to encourage philanthropic donations from grateful patients.

DESIGN, SETTING, AND PARTICIPANTS

Using the Ipsos KnowledgePanel, a probability-based sample representative of the US population, a survey solicited opinions from a primary cohort representing the general population and 3 supplemental cohorts (with high income, cancer, and with heart disease, respectively).

EXPOSURES

Web-based questionnaire.

MAIN OUTCOMES AND MEASURES

Descriptive analyses (with percentages weighted to make the sample demographically representative of the US population) evaluated respondents' attitudes regarding the acceptability of strategies hospitals may use to identify, solicit, and thank donors; perceptions of the effect of physicians discussing donations with their patients; and opinions regarding gift use and stewardship.

RESULTS

Of 831 individuals targeted for the general population sample, 513 (62%) completed surveys, of whom 246 (48.0%) were women and 345 (67.3%) non-Hispanic white. In the weighted sample, 47.0% (95% CI, 42.3%-51.7%) responded that physicians giving patient names to hospital fundraising staff after asking patients' permission was definitely or probably acceptable; 8.5% (95% CI, 5.7%-11.2%) endorsed referring without asking permission. Of the participants, 79.5% (95% CI, 75.6%-83.4%) reported it acceptable for physicians to talk to patients about donating if patients have brought it up; 14.2% (95% CI, 10.9%-17.6%) reported it acceptable when patients have not brought it up; 9.9% (95% CI, 7.1%-12.8%) accepted hospital development staff performing wealth screening using publicly available data to identify patients capable of large donations. Of the participants, 83.2% (95% CI, 79.5%-86.9%) agreed that physicians talking with their patients about donating may interfere with the patient-physician relationship. For a hypothetical patient who donated $1 million, 50.1% (95% CI, 45.4%-54.7%) indicated it would be acceptable for the hospital to show thanks by providing nicer hospital rooms, 26.0% (95% CI, 21.9%-30.1%) by providing expedited appointments, and 19.8% (95% CI, 16.1%-23.5%) by providing physicians' cell phone numbers.

CONCLUSIONS AND RELEVANCE

In this survey study of participants drawn from the general US population, a substantial proportion did not endorse legally allowable approaches for identifying, engaging, and thanking patient-donors.

Differences in regional distribution and inequality in health-resource allocation at hospital and primary health centre levels: a longitudinal study in Shanghai, China

OBJECTIVES

To analyse differences in regional distribution and inequality in health-resource allocation at the hospital and primary health centre (PHC) levels in Shanghai over 7 years.

DESIGN

A longitudinal survey using 2010-2016 data, which were collected for analysis.

SETTING

The study was conducted at the hospital and PHC levels in Shanghai, China.

OUTCOME MEASURES

Ten health-resource indicators were used to measure health-resource distribution at the hospital and PHC levels. In addition, the Theil Index was calculated to measure inequality in health-resource allocation.

RESULTS

All quantities of healthcare resources per 1000 people in hospitals and PHCs increased across Shanghai districts from 2010 to 2016. Relative to suburban districts, the central districts had higher ratios, both in terms of doctors and equipment, and had faster growth in the doctor indicator and slower growth in the equipment indicator in hospitals and PHCs. The Theil Indices of all health-resource allocation in hospitals had higher values compared with those in PHCs every year from 2010 to 2016; furthermore, the Theil Indices of the indicators, except for technicians and doctors in hospitals, all exhibited downward time trends in hospitals and PHCs.

CONCLUSIONS

Increased healthcare resources and reduced inequality of health-resource allocation in Shanghai during the 7 years indicated that measures taken by the Shanghai government to deepen the new round of healthcare reform in China since 2009 had been successful. Meanwhile there still existed regional difference between urban and rural areas and inequality across different medical institutions. To solve these problems, we prescribe increased wages, improved working conditions, and more open access to career development for doctors and nurses; reduced investments in redundant equipment in hospitals; and other incentives for balancing the health workforce between hospitals and PHCs.

Does managed competition constrain hospitals' contract prices? Evidence from the Netherlands

In the Dutch health care system, health insurers negotiate with hospitals about the pricing of hospital products in a managed competition framework. In this paper, we study these contract prices that became for the first time publicly available in 2016. The data show substantive price variation between hospitals for the same products, and within a hospital for the same product across insurers. About 27% of the contract prices for a hospital product are at least 20% higher or lower than the average contract price in the market. For about half of the products, the highest and the lowest contract prices across hospitals differ by a factor of three or more. Moreover, hospital product prices do not follow a consistent ranking across hospitals, suggesting substantial cross-subsidization between hospital products. Potential explanations for the large and seemingly random price variation are: (i) different cost pricing methods used by hospitals, (ii) uncertainty due to frequent changes in the hospital payment system, (iii) price adjustments related to negotiated lumpsum payments and (iv) differences in hospital and insurer market power. Several policy options are discussed to reduce variation and increase transparency of hospital prices.

COVID-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers

The novel COVID-19 came under limelight few months back (December 2019) and has recently been declared a pandemic by WHO. It has resulted in serious financial implications being faced by dental practices, hospitals and healthcare workers. Dental practice currently is restricted to provision of emergency dental care whereas, many hospitals have also cancelled elective procedures to save finances for COVID-19 treatment which is expensive and unpredictable. In addition, healthcare workers are also facing financial challenges in this difficult time. Competent authorities should step in to help dental practices, hospitals and healthcare workers in order to ensure the provision of all types of healthcare efficiently in these testing times and beyond.

Global budget versus cost ceiling: a natural experiment in hospital payment reform in the Netherlands

Global budget (GB) arrangements have become a popular method worldwide to control the rise in healthcare expenditures. By guaranteeing hospital funding, payers hope to eliminate the drive for increased production, and incentivize providers to deliver more efficient care and lower utilization. We evaluated the introduction of GB contracts by certain large insurers in Dutch hospital care in 2012 and compared health care utilization to those insurers who continued with more traditional production-based contracts, i.e., cost ceiling (CC) contracts. We used the share of GB hospital funding per postal code region to study the effect of contract types. Our findings show that having higher share of GB financing was associated with lower growth in treatment intensity, but it was also associated with higher growth in the probability of having at least one hospital visit. While the former finding is in line with our expectation, the latter is not and suggests that hospital visits may take longer to respond to contract incentives. Our study covers the years of 2010-2013 (2 years before and 2 years following the introduction of the new contracts). Therefore, our results capture only short-term effects.

Barriers to chronic Hepatitis B treatment and care in Ghana: A qualitative study with people with Hepatitis B and healthcare providers

BACKGROUND

Hepatitis B viral (HBV) infection remains an important public health concern particularly in Africa. Between 1990 and 2013, Hepatitis B mortality increased by 63%. In recent times, effective antiviral agents against HBV such as Nucleos(t)ide analogs (NAs) are available. These drugs are capable of suppressing HBV replication, preventing progression of chronic Hepatitis B to cirrhosis, and reducing the risk of hepatocellular carcinoma and liver-related death. Notwithstanding, these treatments are underused despite their effectiveness in managing Hepatitis B. This study sought to explore barriers to treatment and care for people with Hepatitis B (PWHB) in Ghana, paying particular attention to beliefs about aetiology that can act as a barrier to care for PWHB.

METHODS

We used an exploratory qualitative design with a purposive sampling technique. Face-to-face interviews were conducted for 18 persons with Hepatitis B (PWHB) and 15 healthcare providers (HCP; physicians, nurses, and midwives). In addition, four focus group discussions (FGD) with a composition of eight HCPs in each group were done. Participants were recruited from one tertiary and one regional hospital in Ghana. Data were processed using QSR Nvivo version 10.0 and analysed using the procedure of inductive thematic analysis. Participants were recruited from one tertiary and one regional hospital in Ghana.

RESULTS

Three main cultural beliefs regarding the aetiology of chronic Hepatitis B that act as barriers to care and treatment were identified. These were: (1) the belief that chronic Hepatitis B is a punishment from the gods to those who touch dead bodies without permission from their landlords, (2) the belief that bewitchment contributes to chronic Hepatitis B, and (3) the belief that chronic Hepatitis B is caused by spiritual poison. Furthermore, individual level barriers were identified. These were the absence of chronic Hepatitis B signs and symptoms, perceived efficacy of traditional herbal medicine, and PWHB's perception that formal care does not meet their expectations. Health system-related barriers included high cost of hospital-based care and inadequate Hepatitis B education for patients from HCPs.

CONCLUSION

Given that high cost of hospital based care was considered an important barrier to engagement in care for PWHB, we recommend including the required Hepatitis B laboratory investigations such as viral load, and the recommended treatment in the National Health Insurance Scheme (NHIS). Also, we recommend increasing health care providers and PWHB Hepatitis B knowledge and capacity in a culturally sensitive fashion, discuss with patients (1) myths about aetiology and the lack of efficacy of traditional herbal medicines, and (2) patients' expectations of care and the need to monitor even in the absence of symptoms.

Defining hospital community benefit activities using Delphi technique: A comparison between China and the United States

Introduction

Currently there is no expert consensus regarding what activities and programs constitute hospital community benefits. In China, the hospital community benefit movement started gaining attention after the recent health care system reform in 2009. In the United States, the Internal Revenue Service and the nonprofit hospital sector have struggled to define community benefit for many years. More recently, under the Affordable Care Act (ACA)’s new “community benefit” requirements, nonprofit hospitals further developed these benefits to qualify for 501(c)(3) tax exempt status.

Methods

The Delphi survey method was used to explore activities and/or programs that are considered to be hospital community benefits in China and the United States. Twenty Chinese and 19 American of academics, senior hospital managers and policy makers were recruited as experts and participated in two rounds of surveys. The survey questionnaire was first developed in China using the 5-point Likert scale to rate the support for certain hospital community benefits activities; it was then translated into English. The questionnaires were modified after the first round of Delphi. After two rounds of surveys, only responses with a minimum of 70 percent support rate were accepted by the research team.

Results

Delphi survey results show that experts from China and the U.S. agree on 68.75 percent of HCB activities and/ or programs, including emergency preparedness, social benefit activities, bad debt /Medicaid shortfall, disaster relief, environmental protection, health promotion and education, education and research, charity care, medical services with positive externality, provision of low profit services, and sliding scale fees.

Conclusions

In China, experts believe that healthcare is a “human right” and that the government has the main responsibility of ensuring affordable access to healthcare for its citizens. Meanwhile, healthcare is considered a commodity in the U.S., and many Americans, especially those who are vulnerable and low-income, are not able to afford and access needed healthcare services. Though the U.S. government recognized the importance of community benefit and included a section in the ACA that outlines new community benefit requirements for nonprofit hospitals, there is a need to issue specific policies regarding the amounts and types of community benefits non-profit hospitals should provide to receive tax exemption status.

An 8-step framework for implementing time-driven activity-based costing in healthcare studies

Micro-costing studies still deserving for methods orientation that contribute to achieve a patient-specific resource use level of analysis. Time-driven activity-based costing (TDABC) is often employed by health organizations in micro-costing studies with that objective. However, the literature shows many deviations in the implementation of TDABC, which might compromise the accuracy of the results obtained. One reason for that can be attributed to the non-existence of a step-by-step orientation to conduct cost analytics with the TDABC specific for micro-costing studies in healthcare. This article aimed at exploring the literature and practical cases to propose an eight-step framework to apply TDABC in micro-costing studies for health care organizations. The 8-step TDABC framework is presented and detailed exploring online spreadsheets already coded to demonstrate data structure and math formula building. A list of analyses that can be performed is suggested, including an explanation about the information that each analysis can provide to increase the organization capability to orient decision making. The case study developed show that actual micro-costing of health care processes can be achieved with the 8-step TDABC framework and its use in future researches can contribute to increase the number of studies that achieve high-quality level in cost information, and consequently, in health resource evaluation.

Revenues and Profits From Medicare Patients in Hospitals Participating in the 340B Drug Discount Program, 2013-2016

IMPORTANCE

The federal 340B program lowers the acquisition cost of prescription drugs and places no limits on what hospitals charge payers. Congress established the program to allow 340B profits (the difference between payments and acquisition costs) to subsidize other safety-net services. Little is known about the magnitude of revenues and profits from the 340B program among participating hospitals.

OBJECTIVE

To report revenues and estimated profits from the 340B program that hospitals collect from Medicare and Medicare beneficiaries for outpatient clinic administration of prescription drugs covered under Medicare Part B.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional descriptive study used 100% Medicare outpatient Part B claims from January 1, 2013, to December 31, 2016, from fee-for-service Medicare beneficiaries administered separately payable drugs at general acute care nonprofit or public hospitals without special payment designations. Claims data (N = 11 298 860) were aggregated to the hospital-year level (N = 6000) and linked to hospital finances and 340B participation from Medicare cost reports and the 340B covered entity list.

MAIN OUTCOMES AND MEASURES

Outcomes studied were revenue and estimated profits, assuming a 50% discount from 340B-discounted drug administrations to Medicare patients, as well as Medicare 340B profits relative to hospital net operating revenue, uncompensated care, and disproportionate share hospital payments.

RESULTS

During the study period, hospitals received approximately $2.1 billion in 340B revenue from Medicare in 2013, increasing to $3.7 billion in 2016. Estimated 340B profits from Medicare in 2016 totaled $1.9 billion, and per-hospital estimated 340B profits were $2.5 million but exhibited variability (median, $0.8 million; interquartile range, $0.1 million-$2.8 million). In 2016, median estimated 340B profits from Medicare were 0.3% (interquartile range, 0.1%-0.7%; mean, 0.4%) of hospital operating budgets and 9.4% (interquartile range, 1.8%-26.5%; mean, 16.6%) of hospital uncompensated care costs.

CONCLUSIONS AND RELEVANCE

Estimated profits that hospitals derived from administering 340B-discounted drugs to Medicare patients are small compared with operating budgets yet substantial compared with uncompensated care costs for many hospitals. Revenue and profit estimates from 340B-discounted drugs represent a lower bound because data on revenue from the sale of outpatient retail dispensed drugs by hospital contract pharmacies and commercial insurer claims are not available.

The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use

AIMS

Adolescents with Type 1 diabetes commonly experience episodes of ketoacidosis. In 2014, we conducted a nationwide survey on the management of diabetic ketoacidosis in young people. The survey reported how individual adolescents with diabetes were managed. However, the costs of treating diabetic ketoacidosis were not reported.

METHODS

Using this mixed population sample of adolescents, we took a 'bottom-up' approach to cost analysis aiming to determine the total expense associated with treating diabetic ketoacidosis. The data were derived using the information from the national UK survey of 71 individuals, collected via questionnaires sent to specialist paediatric diabetes services in England and Wales.

RESULTS

Several assumptions had to be made when analysing the data because the initial survey collection tool was not designed with a health economic model in mind. The mean time to resolution of diabetic ketoacidosis was 15.0 h [95% confidence interval (CI) 13.2, 16.8] and the mean total length of stay was 2.4 days (95% CI 1.9, 3.0). Based on data for individuals and using the British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £1387 (95% CI 1120, 1653). Regression analysis showed a significant cost saving of £762 (95% CI 140, 1574; P = 0.04) among those treated using BSPED guidelines.

CONCLUSION

We have used a bottom-up approach to calculate the costs of an episode of diabetic ketoacidosis in adolescents. These data suggest that following treatment guidelines can significantly lower the costs for managing episodes of diabetic ketoacidosis.

Characteristics of Hospitals That Did and Did Not Join the Bundled Payments for Care Improvement-Advanced Program

This study describes the characteristics of hospitals participating vs not participating and remaining vs leaving the 2018 CMS Bundled Payments for Care Improvement–Advanced Program (BPCI-A), a payment reform model that reimburses for a 90-day episode of care rather than for individual services.

From Board to Bedside: How the Application of Financial Structures to Safety and Quality Can Drive Accountability in a Large Health Care System

BACKGROUND

As the health care system in the United States places greater emphasis on the public reporting of quality and safety data and its use to determine payment, provider organizations must implement structures that ensure discipline and rigor regarding these data. An academic health system, as part of a performance management system, applied four key components of a financial reporting structure to support the goal of top-to-bottom accountability for improving quality and safety.

FOUR KEY COMPONENTS OF A FINANCIAL REPORTING STRUCTURE

The four components implemented by Johns Hopkins Medicine were governance, accountability, reporting of consolidated quality performance statements, and auditing. Governance is provided by the health system's Patient Safety and Quality Board Committee, which reviews goals and strategy for patient safety and quality, reviews quarterly performance for each entity, and holds organizational leaders accountable for performance. An accountability plan includes escalating levels of review corresponding to the number of months an entity misses the defined performance target for a measure. A consolidated quality statement helps inform the Patient Safety and Quality Board Committee and leadership on key quality and safety issues. An audit evaluates the efficiency and effectiveness of processes for data collection, validation, and storage, as to ensure the accuracy and completeness of quality measure reporting.

CONCLUSION

If hospitals and health systems truly want to prioritize improvements in safety and quality, they will need to create a performance management system that ensures data validity and supports performance accountability. Without valid data, it is difficult to know whether a performance gap is due to data quality or clinical quality.

Pay for performance for hospitals

BACKGROUND

Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care.

OBJECTIVES

Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic.

SELECTION CRITERIA

We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables.

MAIN RESULTS

We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance.

AUTHORS' CONCLUSIONS

It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.