The effect of selective contracting on hospital costs and revenues

OBJECTIVE: To examine the effects of selective contracting on California hospital costs and revenues over the 1983-1997 period. DATA SOURCES/STUDY SETTING: Annual disclosure data and discharge data sets for 421 California general acute care hospitals from 1980 to 1997. ANALYSIS: Using measures of competition developed from patient-level discharge data, and financial and utilization measures from the disclosure data, we estimated a fixed effect multivariate regression model of hospital costs and revenues. FINDINGS: We found that hospitals in more competitive areas had a substantially lower rate of increase in both costs and revenues over this extended period of time. For-profit hospitals lowered their costs and revenues after selective contracting was initiated relative to the cost and revenue levels of not-for-profit hospitals. The Medicare PPS has also led high-cost hospitals to lower their costs. CONCLUSIONS: The more competitive the hospital's market, the greater degree to which it has had to lower the rate of increase in costs. A similar pattern exists with regard to hospital revenues. Both of these trends appear to result from the growth of selective contracting. It remains unclear to what extent these cost reductions were the result of increased efficiency or of reduced quality. Since hospital cost growth is sensitive to the competitiveness of its market, antitrust enforcement is a critical element in any cost containment policy.     

Telemedicine in managing demand for secondary-care services

The sustained growth in demand for hospital services has inspired new ways of managing the demands for secondary care. In Finland, teleconsultations have been used alongside an electronic referral system for hospital outpatient clinics for the management of primary-care patients by specialists. Direct outpatient costs of the internal medicine department of a district general hospital with an electronic referral system and using teleconsultations were compared with those of a similar department at another hospital using a paper referral system. The former were at least 20% lower. Almost every paper referral in the conventional system (over 95%) led to an outpatient visit, whereas only one-third of the teleconsultations resulted in actual outpatient visits. Thus virtual integration of secondary and primary care with an electronic referral system as part of an electronic medical record reduced both the costs of hospital outpatient care and the demand for it.     

Dietetic performance indicators: a new management tool

The need for dietetic performance indicators that more accurately reflect the performance of the department of dietetics has led to the development of an effective tool for directors of dietetics to use in monitoring departmental performance, planning departmental activities, services and programs, and budgeting. To follow-up on the work initiated by a group of directors of dietetics in Metropolitan Toronto, the joint Ontario Dietetic Association-Ontario Hospital Association (ODA-OHA) Steering Committee on Alternative Dietetic Performance Indicators (SCADPI) was established. The work of this Committee has involved identifying relevant dietetic performance indicators based on three areas of departmental activity: patient meal service, non-patient meal service, and clinical nutrition service; developing the methodology of allocating food, sundry, and labor costs to these three areas of departmental activity; and testing the validity and feasibility of the methodology among hospitals of varying sizes and levels of dietary department management personnel.     

Hospital charges for colorectal cancer patients first admitted through an emergency department

Some 11,023 colorectal cancer patients diagnosed in 1992-96 in Connecticut first were admitted to a hospital through a hospital emergency department. The average hospital inpatient charges and average length of stay were about 60 percent higher for emergency department versus nonemergency department first admissions. Emergency department status was an important predictor of charges independent of age at diagnosis and length of stay. Applying these data to the approximately 131,000 colorectal cancers diagnosed in 1998 in the U.S., estimated excess hospital costs due to emergency department versus nonemergency department first admissions for colorectal cancer were about $328 million.     

Case management: a controlled evaluation of persons with diabetes

Case management has been widely used with the intent of improving clinical outcomes while reducing medical costs. Studies of case management, however, have shown variable effectiveness. This study assessed the impact of a state health department case management program on hospitalizations, emergency department (ED) visits, and preventive services among persons with diabetes receiving Medicaid fee-for-service health care. The patients enrolled in the non-disease-specific case management program were low-income, chronically ill and medically complex. Nurse case managers authorized and coordinated services in the home for these patients and established links to health-care professionals and community resources. A retrospective, non-randomized, controlled time series design using paid claims files was employed. Case management reduced admissions and hospital days but did not significantly impact ED visits or use of preventive services.     

Benefits and costs of a free community-based primary care clinic

This study estimates the benefits and costs of a free clinic providing primary care services. Using matched data from a free clinic and its corresponding regional hospital on a sample of newly enrolled clinic patients, patients' non-urgent emergency department (ED) and inpatient hospital costs in the year prior to clinic enrollment were compared to those in the year following enrollment to obtain financial benefits. We compare these to annual estimates of the costs associated with the delivery of primary care to these patients. For our sample (n = 207), the annual non-urgent ED and inpatient costs at the hospital fell by $170 per patient after clinic enrollment. However, the cost associated with delivering primary care in the first year after clinic enrollment cost $505 per patient. The presence of a free primary care clinic reduces hospital costs associated with non-urgent ED use and inpatient care. These reductions in costs need to be sustained for at least 3 years to offset the costs associated with the initially high diagnostic and treatment costs involved in the delivery of primary care to an uninsured population.     

An evaluation of subsidized rural primary care programs: IV. Impact of the rural hospital on clinic self-sufficiency.

Subsidized rural clinics and providers have long depended on the rural hospital for the care of some of their patients; the hospital has also been a source of revenue for these providers and programs. We studied a representative national sample of 116 subsidized rural clinics, focusing on the impact on rural clinic costs and revenues of the use of the hospital by the clinics' providers. Both clinic costs and revenue are reduced by the use of the hospital by rural practice providers, but costs are lowered to a greater extent than revenues, thereby enhancing the financial self-sufficiency of the subsidized clinic. The cost savings affect all aspects of clinic operation, but especially laboratory costs, community services costs, and administrative costs. The dependence of these rural clinics on the hospital indicates that the condition of subsidized rural clinics would be worsened by decreased availability of hospital services.     

A volunteer feeding assistance program can improve dietary intakes of elderly patients--a pilot study

Malnutrition is prevalent in elderly hospitalized patients and has been associated with longer lengths of stay (LOS), higher rates of complications and increased hospital costs. Feeding assistance has traditionally been the role of nurses, however with an ageing population and an ever-increasing workload there may not be sufficient time to ensure the nutritional care of all patients. A program in which trained volunteers assist, socialize and feed nutritionally vulnerable patients at lunch on weekdays has been initiated in a major suburban hospital in Sydney. The pilot study reported here aimed to evaluate the lunchtime assistance program in terms of dietary intakes by comparing data from weekdays (with volunteers) and that from weekends (no volunteers). Nine patients (mean age+/-S.D.: 89+/-4.6 years) participated in the study. Observations and weighed plate waste were recorded for each patient at lunch on two weekdays and the following two weekend days. When volunteers were present, the average protein intake increased by 10.1g at lunch (p<0.05) and 10.7 g over the whole day (p<0.05). There was also a trend to increased energy intake. Observations indicated that the volunteers, when compared to the nurses, socialized more with patients, encouraged them to eat more often and spent more time feeding them. Trialing volunteer assistance in a larger study would be useful.     

<Emphasis Type="Bold">Community Health Workers Bring Cost Savings to Patient-Centered Medical Home</Emphasis>s

The Patient-Centered Medical Home (PCMH) model demonstrated that processes of care can be improved while unnecessary care, such as preventable emergency department utilization, can be reduced through better care coordination. A complementary model, the Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health. However, the PCMH model puts downward pressure on the panel sizes of primary care providers, increasing the average fixed costs of care at the practice level. While the I-PaCS model layers an additional cost of the CHWs into the primary care cost structure, that additional costs is relatively small. The purpose of this study is to simulate the effects of the PCMH and I-PaCS models over a 3-year period to account for program initiation to maturity. The costs and cost offsets of the model were estimated at the clinic practice level. The studies which find the largest cost savings are for high-risk, paneled patients and therefore do not represent the effects of the PCMH model on moderate-utilizing patients or practice-level effects. We modeled a 12.6% decrease in the inpatient hospital, outpatient hospital and emergency department costs of high and moderate risk patients. The PCMH is expected to realize a 1.7% annual savings by year three while the I-PaCS program is expected to a 7.1% savings in the third year. The two models are complementary, the I-PaCS program enhancing the cost reduction capability of the PCMH.     

消毒供应中心可追溯管理系统建设及应用

介绍了南京医科大学第一附属医院消毒供应中心可追溯管理系统的整体架构,设计思路,系统开发环境。使用方法及其的应用情况。通过追溯系统的上线,有效降低感染发生,进一步简化供应室工作任务,在降低院方成本的同时提高各科室的工作效率,实现利用现代信息化技术为医院提供科学质量管理的目标。     

Pharmacy and materiel management: a profitable alliance

According to the author, materiel management can be a catalyst to a mutually beneficial relationship between their department and the pharmacy, particularly in wholesaler selection, buying group decisions and inventory control--if they use the right approach.     

“本·量·利”模型解析精神病医院的经营效益

本文以本.量.利模型,将某精神病医院2008年的成本,分解为门诊和住院成本并预测其保本点工作量。门诊部门能够达到保本点工作量,略有盈余;住院部保本点工作量差距很大,处于亏损状态,导致整个医院亏损。深入分析医院亏损原因有五个,并提出针对性改进策略。     

Potentially preventable hospital use for dental conditions: implications for expanding dental coverage for low income populations

Recently, attention has been placed on the issue of poor access to dental care, and the implications this may have for health care systems, in particular emergency department use for basic dental problems. In 2006, approximately 26,000 of 12 million Ontarians used acute-care hospital services for select dental problems, representing a cost of $16.4 million. There were 964 hospital admissions. The majority of use is by low-income adults. Although better access to dental care may lessen this burden on the health care system, the potential costs averted are considerably less than current proposals to improve access to dental care for low-income groups in Canada. Justifying renewed government investments in dental care in economic terms will require a broader assessment of costs; these data provide a starting-point for policymakers.     

Parenteral nutrition (PN) use for adult hospitalized patients: a study of usage in a tertiary medical center.

The use of parenteral nutrition (PN) is essential for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many earlier studies have noted that PN is often inappropriately used in the hospital setting, thereby increasing the risk of associated complications and costs. A prospective study was performed at the Medical University of South Carolina (MUSC), using a nutrition support database to determine the appropriateness of PN use and the associated hospital costs for patients on 3 surgical services over a 6-month period. Appropriateness of PN therapy was determined according to the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines. A total of 139 new PN therapies were initiated in the 6-month period. Forty percent of the cases were deemed inappropriate. A total of 573 PN days ($80,000 hospital PN costs) could have been saved if inappropriate PN therapy had not been ordered. The avoidable costs only reflect the PN solution and not the additional costs associated with laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management. This study illustrated that PN was not always being provided according to A.S.P.E.N. guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who meet these guidelines.     

南京医科大学第一附属医院RIS＆PACS项目实施要点

南京医科大学第一附属医院的放射信息管理系统（RIS）、医学影像的存储和传输系统（PACS）涵盖了主要的医技诊疗科室,大幅度地改善并优化了整个医院医疗工作的流程,在院内实现了无胶片化的应用模式,从而大大降低了医院的运营成本,提高了医院的运作效率。本文就此介绍并分析了系统安装与调试的成功经验和此类项目在实施过程中应注意的问题。     

Hospital Length of Stay and Cost: A Multilevel Modeling Analysis

Despite concern over compromised medical care resulting from a recent decline in the length of hospitalizations, little attention has been given to the extent to which this strategy has led to cost savings for hospitals. This article examines this issue using a multilevel modeling methodology that examines patient costs as they relate to both patient and hospital level characteristics. The analysis reveals an estimated elasticity of patient length of stay of 0.755 and of 0.326 for hospital level average length of stay. It appears from these results that the strategy of reducing the lengths of hospitalizations has saved considerably on hospital costs.     

Hospital-based versus free-standing primary care costs

A survey of the literature supports the broad generalization that primary care delivered in this hospital outpatient department will be more expensive than care provided in a free-standing setting. Among the reasons discussed by the author are: (1) reimbursement policies of third party insurors which mask and inflate the distribution of the true costs of care within the hospital; (2) lack of control by outpatient department directors over their own costs; (3) the degree to which the availability of sophisticated and expensive technology within the hospital setting encourages its utilization; and (4) the differences in case mix: "sicker" patients are seen in outpatient departments. Gold recognizes that most studies to date contain serious limitations in their generalizability; she concludes that additional studies are necessary to explain why the costs vary to the extent they do. She also suggests studying other issues such as access, consumer preferences, provider preferences and training requirements, and quality of care before reaching any decisions about the future of hospital-based primary care.     

Higher diet quality does not predict lower Medicare costs but does predict number of claims in mid-aged Australian women

Optimal dietary quality, indicated by higher diet quality index scores, reflects greater adherence to National dietary recommendations and is also associated with lower morbidity and mortality from chronic disease. Whether this is reflected in lower health care cost over time has rarely been examined. The aim of this study was to examine whether higher diet quality, as measured by the Australian Recommended Food Score (ARFS), was associated with lower health care costs within the mid-aged cohort of the Australian Longitudinal Study on Women's Health. We found that there was a statistically significant association between five year cumulative costs and ARFS, but in the opposite direction to that predicted, with those in the highest quintiles of ARFS having higher health care costs. However the number of Medicare claims over the six year period (2002-2007) was lower for those in the highest compared with the lowest quintile, p = 0.002. There is a need to monitor both costs and claims over time to examine health care usage in the longer term in order to determine whether savings are eventually obtained for those with the dietary patterns that adhere more closely to National recommendations.     

General Practitioners and Hospital-Initiated Prescribing

Objectives: Prescribing costs have risen significantly over the past decade and this has led to increasing pressure on general practitioners (GPs) to control their prescribing budgets. This paper explores GPs' perceptions of the influences of hospital-initiated prescribing on how they manage their prescribing budget.

Method: 16 practices within Birmingham Health Authority were selected according to characteristics of their prescribing budget. Twenty-one GPs in these practices were interviewed in depth about their views on how they controlled their prescribing budget, including questions on hospital-initiated prescribing.

Results: GPs reported being influenced by the experience of seeing patients who had been prescribed particular drugs by a consultant and then following their example. However, GPs expressed dissatisfaction with some hospital-initiated prescribing. Sometimes they considered the choice of drugs for conditions commonly treated in primary care to be unnecessarily expensive. They were also concerned about more expensive and more specialist drugs. GPs found it difficult to change or refuse to prescribe medication which had been initiated in hospital because they felt it could be damaging to their relationship both with their patients and consultants.

Conclusions: Hospital prescribing can have a major impact on general practice budgets and GPs felt that their ability to contain costs was not always within their control. The GPs expressed a wide range of views on how to respond to prescribing initiated in hospital with which they did not feel comfortable.