Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration.

A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes. We identified two major organizational responses. One principal strategy was to reduce SNF referrals, using risk-stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. Another was to enhance integration with SNFs: fifteen hospitals or health systems in our sample had formed networks of preferred SNFs to exert influence over SNF quality and costs. Common coordination strategies included sharing access to electronic medical records, embedding providers across facilities, hiring dedicated care coordination staff, and creating platforms for data sharing. As hospitals presumably move toward home-based care and more selective SNF referrals, more evidence is needed to understand how these discharge practices affect the quality of care and patient outcomes.

Point-of-Care Ultrasound Work Flow Innovation: Impact on Documentation and Billing.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Bundled payments: a glimpse into the future?

As part of its mission to cut costs and improve quality, the Centers for Medicare & Medicaid Services (CMS) has launched a pilot project that pays a fixed price for health services by multiple providers over a period of time. Case managers need to make sure that the care patients receive in the hospital is appropriate and can't be provided in another, less costly and less restrictive setting. Hospitals are going to have to evaluate their current practice patterns to identify potential areas for improvement and adopt the most efficient practices. Case managers must have accurate information about patients and their benefits to create the most appropriate and cost-effective discharge plan.

Vertical integration: hospital ownership of physician practices is associated with higher prices and spending.

We examined the consequences of contractual or ownership relationships between hospitals and physician practices, often described as vertical integration. Such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals. We investigated the impact of vertical integration on hospital prices, volumes (admissions), and spending for privately insured patients. Using hospital claims from Truven Analytics MarketScan for the nonelderly privately insured in the period 2001-07, we constructed county-level indices of prices, volumes, and spending and adjusted them for enrollees' age and sex. We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians. We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians--ownership of physician practices--was associated with higher hospital prices and spending. We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.

Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact.

OBJECTIVES: The aim of this study was to determine the fiscal impact of implementation of a novel emergency department (ED) point-of-care (POC) ultrasound billing and reimbursement program. METHODS: This was a single-center retrospective study at an academic medical center. A novel POC ultrasound billing protocol was implemented using the Q-path Web-based image archival system. Patient care ultrasound examination reports were completed and signed electronically online by faculty using Q-path. A notification was automatically sent to ED coders from Q-path to bill the scans. ED coders billed the professional fees for scans on a daily basis and also notified hospital coders to bill for facility fees. A fiscal analysis was performed at the end of the year after implementing the new billing protocol, and a before-and-after comparison was conducted. RESULTS: After implementation of the new billing program, there was a 45% increase in the ED faculty participation in billing for patient care examinations (30%-75%). The number of ultrasound examinations billed increased 5.1-fold (4449 vs 857) during the post implementation period. The total units billed increased from previous year for professional services to 4157 from 649 and facility services to 3266 from 516. During the post implementation period, the facility fees revenue increased 7-fold and professional fees revenue increased 6.34-fold. After deducting the capital costs and ongoing operational costs from approximate collections, the net profits gained by our ED ultrasound program was approximately $350000. CONCLUSIONS: Within 1 year of inception, our novel POC ultrasound billing and reimbursement program generated significant revenue through ultrasound billing.

Developing a consumer pricing strategy.

Healthcare providers can learn a variety of pricing lessons from the retail market: For providers, wholesale pricing--"the price to play"--alone is not enough. Once a hospital or health system chooses a market position, the provider creates an expectation that must be met-consistently. Consumer loyalty is fluid, and the price of care or service is not always the motivator for choosing one organization over another; intangibles such as location and level of customer service also drive purchasing decisions.

[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

Evaluation of the introduction of a diagnosis procedure combination system for patient outcome and hospitalisation charges for patients with hip fracture or lung cancer in Japan.

OBJECTIVES: To evaluate the effects of introducing the Diagnosis Procedure Combination (DPC) system on outcomes, length of stay (LOS) and hospitalisation charges for patients with hip fractures or lung cancer. Patient outcome was evaluated by inpatient mortality, condition at discharge, and readmission within 42 days after discharge. METHODS: DPC data were collected from 92 Japanese Red Cross Medical Centres and community hospitals between April 2005 and December 2008. Pre- and post-DPC outcomes were compared by multivariate regression with difference-in-difference analysis. RESULTS: For hip fractures, the percentage of patients in worse condition at discharge was 150% higher when DPC was used [odds ratio (OR)=2.556, P<0.001]. For lung cancer, the percentage of patients in worse condition at discharge was about 30% lower when DPC was used (OR=0.697, P=0.001). The number of lung cancer diagnosis groups that did not require a long LOS increased. Inpatient mortality and readmission rates and hospitalisation charges did not change for either diagnosis, though the average LOS decreased. CONCLUSIONS: Under the DPC system in Japan, some patients would be discharged 'quicker' and 'sicker', but other patients' outcome at discharge improved. Although LOS decreased, hospitalisation charges did not decrease, and the readmission rate did not increase.

Hospital billing for blood processing and transfusion for inpatient stays.

Medicare, an important payer for hospitals, reimburses hospitals for inpatient stays using Diagnosis Related Groups (DRGs). Many private insurers also use the DRG methodology to reimburse hospitals for their services. Therefore, those blood service organizations that bill Medicare directly require an understanding of the DRG system of payment to enable them to bill Medicare correctly, and in order to be certain they are adequately reimbursed. Blood centers that do not bill Medicare directly need to understand how hospitals are reimbursed for blood and blood components as this affects a hospital's ability to pay service fees related to these products. This review presents a detailed explanation of how hospitals are reimbursed by the Centers for Medicare and Medicaid Services (CMS) for Medicare inpatient services, including blood services.

Profile of hospital charges for chronic conditions by health status and severity level: a case study of 4 provinces in Thailand.

The objective of this study is to identify charges for common chronic patients, by health status and severity of illness. Patients having 4 common chronic diseases-diabetics, hypertension, chronic lower respiratory diseases, and chronic renal failure-from 4 provinces were included (between 2002 and 2004). Patients were classified into clinically defined and health plan categories; charges were analyzed according to core health status and severity level of the chronic disease groups. Patients classified as single chronic condition (69.8%) had mean annual charges between 4089 and 7461 baht. Patients with multiple chronic conditions (30.2%) had mean annual charges varying, by health status and severity, from 611 to 16 794 baht, accounting for 40% of the total charges. Distribution of charges varied across health status groups. 1 USD = 35.1 baht The percentages of chronic health expenditures vary according to health status and severity of illness. This analysis can be used to identify patients for various purposes.