Payment of Emergency Department Bills by Medicaid Patients

Objective : To analyze ED services used by and payment received from patients who request to stay and assume responsibility for their bills after being denied emergency care payment by their Medicaid providers.
Methods : A retrospective chart review over an 18-month period was conducted. Charges for these visits were obtained from the physician billing service and hospital finance records.
Results : Of 193 patient visits identified, 192 charts were located and reviewed for chief complaint, diagnostic tests, and interventions performed. In total, the visits resulted in $18,120 in physician charges and $28,126 in hospital charges. Three payments amounting to $134 were collected, leaving $46,246 in nonreimbursed charges.
Conclusions : Nearly all patients who elect to be seen in this pediatric ED after being denied by their Medicaid managed care providers do not pay their bills. ED resources, including laboratory studies, radiographs, and consultations, are used to evaluate and treat these patients without compensation. The cost of this nonreimbursed care must be recovered from other patient care charges.     

Can home visits help reduce hospital readmissions? Randomized controlled trial

Title. Can home visits help reduce hospital readmissions? Randomized controlled trial Aim. This paper is a report of a study to determine whether home visits can reduce hospital readmissions. Background. The phenomenon of hospital readmission raises concerns about the quality of care and appropriate use of resources. Home visits after hospital discharge have been introduced to help reduce hospital readmission rates, but the results have not been conclusive. Method. A randomized controlled trial was carried out from 2003 to 2005 . The control group (n = 166) received routine care and the study group (n = 166) received home visits from community nurses within 30 days of hospital discharge. Data were collected at baseline before discharge and 30 days after discharge. Findings. Patients in the study group were statistically significantly more satisfied with their care. There were no statistically significant differences in other outcomes, including readmission rate, ADL score, self‐perceived life satisfaction and self‐perceived health. Regression analysis revealed that self‐perceived life satisfaction, self‐perceived health and disease category other than general symptoms were three statistically significant variables predicting hospital readmissions. Conclusion. Preventive home visits were not effective in reducing hospital readmissions, but satisfaction with care was enhanced. Subjective well‐being is a key variable that warrants attention in the planning and evaluation of postdischarge home care.     

A staged management diabetes foot program versus standard care: a 1-year cost and utilization comparison in a state public hospital system

OBJECTIVE: To determine whether staged management of foot ulcers reduces health care costs and utilization. DESIGN: Nonrandomized retrospective study using data from 1998-1999 in the Louisiana public hospital system. SETTING: Louisiana public hospital system. PARTICIPANTS: Forty-five patients with diabetes foot ulcer who received staged management foot care and 169 patients with diabetes foot ulcer who received standard foot care. INTERVENTIONS: Staged management of foot ulcers consisting of devices to offload pressure; self-care education; and, after healing, custom-fabricated orthoses and footwear, and monitored progressive ambulation. MAIN OUTCOME MEASURES: One-year levels of the number of foot-related inpatient hospitalizations, number of amputation-related hospitalizations, total number of foot-related inpatient days, total charges for foot-related inpatient hospitalizations, all-cause outpatient visits, total charges for all-cause outpatient visits, and combined outpatient and foot-related inpatient charges. RESULTS: Over the 12-month study period, the staged management group had a lower foot-related hospitalization rate than did the comparison group (.09 admissions per person vs.50 admissions per person, P=.0002); lower foot-related inpatient days (.91d per person vs 3.97d per person, P=.0289); lower foot-related inpatient charges ($1321 per person vs $5411 per person, P=.0151); fewer amputation-related hospitalizations (.04 per person vs.19 per person, P=.0351); fewer emergency department visits (.60 visits per person vs 1.22 visits per person, P=.0043); lower emergency department charges ($104 per person vs $208 per person, P=.0057); and lower total charges ($4776 per person vs $9402 per person, P=.0141). The staged management group had a higher number of outpatient visits (24.91 per person vs 8.04 per person, P<.0001) and higher outpatient charges ($2169 per person vs $1471 per person, P<.0001). CONCLUSIONS: A staged management diabetes foot program significantly reduced emergency department and hospital utilization and charges in a statewide public hospital system.     

Impact of a nurse-managed heart failure clinic: a pilot study.

BACKGROUND: One approach to optimize clinical and economic management of congestive heart failure is the use of multidisciplinary outpatient clinics in which advanced practice nurses coordinate care. One such clinic was developed in 1995 at a southeastern university hospital to enhance management of patients with chronic congestive heart failure. OBJECTIVES: To evaluate the effects of a multidisciplinary outpatient heart failure clinic on the clinical and economic management of patients with congestive heart failure. METHODS: Data on hospital readmissions, emergency department visits, length of stay, charges, and reimbursement from the 6 months before 15 patients joined a heart failure clinic were compared with data from the 6 months after the patients joined the clinic. RESULTS: The patients had a total of 38 hospital admissions (151 hospital days) in the 6 months before joining the clinic and 19 admissions (72 hospital days) in the 6 months afterward. The mean length of stay decreased from 4.3 days in the 6 months before joining to 3.8 days in the 6 months afterward, and the number of emergency department visits also decreased, although neither decrease was statistically significant. Mean inpatient hospital charges decreased from $10,624 per patient admission to $5893. Reimbursements were $7751 (73% collection rate) and $5138 (87% collection rate), respectively. CONCLUSIONS: Patients seemed to benefit from participation in the heart failure clinic. If a healthcare provider is available to manage early signs and symptoms of worsening heart failure, hospital readmissions may be decreased and patients' outcomes may be improved.     

The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs

OBJECTIVE: To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management. BACKGROUND: In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality. METHODS: Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured. RESULTS: Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P<.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions. CONCLUSIONS: Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.     

Success of a Nurse Practitioner–led Interdisciplinary Team

The nurse practitioner–led interdisciplinary team (IDT) was established to reduce readmissions by optimizing care for a select group of high-risk patients. Two new standards of care were established: weekly IDT meetings leading to implementation of a shared care plan and standard workflows for posthospital visits. The new standard of care resulted in a median readmission rate reduction from 28% (10%-32%) to 9% (4%-12%). The nurse practitioner–led IDT reduced the median readmission rate by 64%.     

Effect of a nurse-directed diabetes disease management program on urgent care/emergency room visits and hospitalizations in a minority population

OBJECTIVE: To evaluate whether nurse-directed diabetes care reduced preventable diabetes-related urgent care/emergency room visits and hospitalizations in a minority population. RESEARCH DESIGN AND METHODS: Diabetic patients who receive care in a county public health clinic were randomly selected for a Diabetes Managed Care Program (DMCP) in which a specially trained nurse followed detailed treatment algorithms to provide diabetes care for 1 year. Preventable diabetes-related urgent care/emergency room visits and hospitalizations for these patients incurred during the intervention year and the year before enrollment were compared. Preventable diabetes-related causes were defined as metabolic (diabetic ketoacidosis, hyperglycemia, or hypoglycemia) or infection (cellulitis, foot ulcer, osteomyelitis, fungal infection, or urinary tract infection). RESULTS: Use of the urgent care/emergency room and hospitalizations during the intervention year and the year prior were available for 331 patients who completed the DMCP intervention. There were 95 [corrected] total urgent care/emergency room visits and hospitalizations in the year before entering the DMCP and 52 [corrected] during the DMCP year, a 45[corrected]% reduction. Preventable diabetes-related episodes were far fewer. During the prior year, 14 patients made 15 urgent care/emergency room visits and 5 patients incurred 6 hospitalizations. During the DMCP year, four different patients made five emergency room/urgent care visits and one other patient was hospitalized. Preventable diabetes-related use was significantly (P < 0.001) lower during the intervention year compared with the prior year. Total charges for urgent care/emergency room visits and hospitalizations only (not other charges related to diabetes care) during the year before entering the DMCP were $129,176 compared with $24,630 during the DMCP year. CONCLUSIONS: When compared with usual care, nurse-directed diabetes care resulted in significantly fewer urgent care/emergency room visits and hospitalizations for preventable diabetes-related causes. Policy makers seeking to improve diabetes care and conserve resources should seriously consider adopting this approach.     

院外管理提高慢性心力衰竭患者的康复效果

目的 探讨院外管理对慢性心力衰竭患者症状困扰、日常活动能力及再次住院率的影响.方法 便利选取2012年5月至2013年3月慢性心力衰竭患者84例,按住院号的奇偶性分为对照组43例和试验组41例,对照组给予常规的出院指导及电话随访,试验组在此基础上实施院外管理,即在出院后第1周及第1、2、3个月给予院外指导、症状评估、自我护理实施情况评估.于出院前、出院后3个月对研究对象进行症状困扰测评及6 min步行试验,并比较两组患者出院后3个月内因心力衰竭急诊或再次住院的相关数据.结果 出院3个月后,试验组患者呼吸困难、疲劳、心悸、胸闷以及水肿困扰程度较对照组明显减轻,6 min步行距离较对照组明显增加（P＜0.05或P＜0.01）;试验组患者因心力衰竭急诊和再次住院的比例均低于对照组,差异有统计学意义（P＜0.05）.结论 有效的院外管理能够减轻心力衰竭患者的症状困扰,改善运动功能状态,降低急诊就诊率和再次住院率.     

Intravenous nesiritide in acute heart failure

The purpose of this study is to evaluate the effect of nesiritide on length of hospital stay, readmission rates, and charges compared with usual care for congestive heart failure (CHF). Using a structured retrospective chart review, we reviewed the records of 127 patients admitted with decompensated CHF, looking at length of stay on initial admission, readmission rates, total hospital days over 3 months, 3-month mortality, pharmacy and hospital charges for the initial admission, and total pharmacy and hospital charges over 3 months. Nesiritide had no effect on initial length of stay, readmission rates, or 3-month mortality. Patients with an ejection fraction >30% who received nesiritide spent more days in the hospital over 3 months than those who received usual care, although there were no differences between the groups in patients with an ejection fraction of < or =30%. Pharmacy and hospital charges for both the initial admission and over 3 months were significantly higher for patients who received nesiritide than for those who received usual care. Patients who received nesiritide incurred significantly higher charges for medical care, but nesiritide did not affect length of stay, readmission rates, or mortality.     

Dispensing home nebulizers for acute wheezing from the hospital is cost-effective

The objective was to investigate the use characteristics of home nebulizers and to measure the benefit gained from dispensing home nebulizers (compared with their cost) to patients from the hospital. During the study period, August 28,1996 to May 17,1997, a sample of 232 of the 291 entries from a log of home nebulizers dispensed by the hospital respiratory care department were surveyed over the telephone. Of the 232 study subjects under the age of 21, a telephone interview of a guardian or supervising adult was completed in 106 subjects (46%) a mean of 43 weeks after the home nebulizer was prescribed (47% of the cohort received their home nebulizers from the inpatient service and another 47% were discharged with home nebulizers from the emergency department (ED)). An average of 3.6 estimated additional ED visits and 5.4 office/clinic visits for each patient were prevented by the home nebulizer. The benefit (savings from reduced ED and office visits alone) to cost ratio estimates range from $855:$90 to $1710:$90 or more. The overwhelming majority of the patients felt that the home nebulizer was a good idea, it was easy to use, they had no problems with the nebulizer and they received adequate training for home nebulizer use. Home nebulizers are a cost-effective means of providing home nebulized albuterol for selected outpatients. Hospital inpatient units and EDs which have the ability to dispense a home nebulizer, have an additional therapeutic option available for selected patients who may benefit from it. Medical insurance companies should fully support (ie, pay for) home nebulizers because it is cost effective. If there is any concern about the reliability of the patient to follow-up with their primary physician, the patient's primary physician should be contacted to discuss the feasibility of discharging the patient with a home nebulizer.     

Care of minor burn injuries: an analysis of burn clinic and emergency room charges

Most burn injuries are minor in nature and can be managed on an outpatient basis. Such patients are usually evaluated and treated in emergency departments (ED) rather than in specialized outpatient burn care facilities. Although many burn centers maintain such facilities for the initial care of these patients, this practice is not commonplace because of conflicting interests of the ED and burn team. We first analyzed the hospital charges for all thermally injured patients admitted for a period of < or = 24 hours between April 1996 and August 1998. This was followed by an independent analysis of the hospital charges for all outpatient visits to the burn clinic and ED during calendar year 1998. Physician charges were not included in the second study. Patients admitted for < or = 24 hours had mean hospital charges of $1185 when initially evaluated in the ED compared with $691 if they were directly admitted to the burn unit (P < 0.001). This difference was largely because of higher charges for medication, laboratory, radiologic studies, and the ED visit charges. In the second study the mean charge for care administered in the ED was $192 compared with $139 for treatment in the outpatient burn clinic (P < 0.0001). Patients treated in the burn clinic had significantly lower radiology and treatment charges but significantly higher pharmacy charges than patients treated in the ED. These data have supported our efforts to develop a walk-in burn treatment center. Such a program should not only result in reduced charges for care, but also enhance patient access to the expertise of the multidisciplinary burn team and help ensure optimal outcomes.     

Impact of an interprofessional transition of care service on 30-day hospital reutilizations

The objective of this study was to evaluate the impact of an interprofessional Transitions of Care (TOC) service on 30-day hospital reutilization inclusive of hospital readmissions and ED visits. This was a retrospective cohort study including patients discharged from an academic medical center between September 2013 and October 2014. Patients scheduled for a hospital follow-up visit in the post-acute care clinic (PACC) were included in the intervention group and patients without a post-discharge interprofessional TOC service were included in the comparison group. The intervention included a hospital follow-up visit with an interprofessional healthcare team. The primary composite outcome was hospital reutilization, defined as a hospital readmission or ED visit within 30 days of the discharge date. Overall, 330 patients were included in each group. In the intention-to-treat analysis, the primary composite outcome was not significantly different between groups (16.97% vs. 19.39%, P = 0.4195) whereas in the per-protocol analysis (all patients who showed to their PACC appointment), the primary outcome was significantly different in favor of the intervention group (9.28% vs. 19.39%, P = 0.0009). When components were analyzed separately, there was a statistically significant difference in favor of intervention group for hospital readmissions, but there was no difference for ED visits. This study demonstrates that an outpatient interprofessional TOC service with patient engagement from a team of nurses, pharmacists, physicians, and social workers may reduce 30-day hospital readmissions but may not impact 30-day ED visits.     

Care Models Preventing Readmission

ObjectivesThis article aims to identify the steps necessary to evaluate the clinical need for innovative coverage models within the oncology setting to help prevent hospital readmissions.Data SourcesMultiple published studies suggest alternative methods for patient care delivery that are safe and cost effective.ConclusionImproving care transitions for the oncology patient is necessary to be able to provide low-cost, high-quality, and patient-centered care. Many of the review studies in this article suggest that emergency room visits and subsequent readmission could be decreased with the use of innovative care models.Implications for Nursing PracticeNurses are critical to the care of medically fragile patients. Nurse-led activities such as telephone triage, post discharge phone calls, or telehealth visits can reduce patient emergency department utilization and readmissions through early recognition of symptoms and oncologic emergencies by prompting timely referrals/consultations and quick interventions.     

The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions.

This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.     

Predictors and Outcomes of Frequent Emergency Department Users

OBJECTIVE: To identify predictors and outcomes associated with frequent emergency department (ED) users. METHODS: Cross-sectional intake surveys, medical chart reviews, and telephone follow-up interviews of patients presenting with selected chief complaints were performed at five urban EDs during a one-month study period in 1995. Frequent use was defined by four or more self-reported, prior ED visits. Multivariate logistic regression identified predictors of frequent ED visitors from five domains (demographics, health status, health access, health care preference, and severity of acute illness). Associations between high use and selected outcomes were assessed with logistic regression models. RESULTS: All study components were completed by 2,333 of 3,455 eligible patients (67.5%). Demographics predicting frequent use included being a single parent, single or divorced marital status, high school education or less, and income of less than $10,000 (1995). Health status predictors included hospitalization in the preceding three months, high ratings of psychological distress, and asthma. Health access predictors included identifying an ED or a hospital clinic as the primary care site, having a primary care physician (PCP), and visiting a PCP in the past month. Choosing the ED for free care was the only health preference predictive of heavy use. Illness severity measures were higher in frequent visitors, although these were not independently predictive in the multivariate model. Outcomes correlated with heavy use include increased hospital admissions, higher rates of ED return visits, and lower patient satisfaction, but not willingness to return to the ED or follow-up with a doctor. CONCLUSIONS: Frequent ED visits are associated with socioeconomic distress, chronic illness, and high use of other health resources. Efforts to reduce ED visits require addressing the unique needs of these patients in the emergency and primary care settings.     

Hospital readmissions and quality of care.

BACKGROUND: Readmission rates are often proposed as markers for quality of care. However, a consistent link between readmissions and quality has not been established. OBJECTIVE: To test the relation of readmission to quality and the utility of readmissions as hospital quality measures. SUBJECTS: One thousand, seven hundred and fifty-eight Medicare patients hospitalized in four states between 1991 to 1992 with pneumonia or congestive heart failure (CHF). DESIGN: Case control. MEASURES: Related adverse readmissions (RARs), defined as readmissions that indicate potentially sub-optimal care during initial hospitalization, were identified from administrative data using readmission diagnoses and intervening time periods designated by physician panels. We used linear regression to estimate the association between implicit and explicit quality measures and readmission status (RARs, non-RAR readmissions, and nonreadmissions), adjusting for severity. We tested whether RARs were associated with inferior care and performed simulations to determine whether RARs discriminated between hospitals on the basis of quality. RESULTS: Compared with nonreadmitted pneumonia patients, patients with RARs had lower adjusted quality measured both by explicit (0.25 standardized units, P = 0.004) and implicit methods (0.17, P = 0.047). Adjusted differences for CHF patients were 0.17 (P = 0.048) and 0.20 (P = 0.017), respectively. In some analyses, patients with non-RAR readmissions also experienced lower quality. However, rates of inferior quality care did not differ significantly by readmission status, and simulations identified no meaningful relationship between RARs and hospital quality of care. CONCLUSIONS: RARs are statistically associated with lower quality of care. However, neither RARs nor other readmissions appear to be useful tools for identifying patients who experience inferior care or for comparing quality among hospitals.