The Effect of Cuts in Medicare Reimbursement on Hospital Mortality

Objective. To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected.
Data Source. Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001.
Study Design. A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania.
Data Collection. We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted.
Principal Findings. The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals ( p <.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals ( p =.04–.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals.
Conclusions. An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.     

Time to death and health expenditure: an improved model for the impact of demographic change on health care costs

BACKGROUND: Obtaining well-founded estimates of the effect of demographic change on future health expenditures is a pressing issue in all developed countries. Thus far, expenditure projections have examined the effect of age on health care costs, but fail to account for the influence of remaining life expectancy on costs. OBJECTIVE: This paper seeks to create a more accurate projection model that considers the concentration of costs towards the end of life, and to compare this model with the more traditional approach that holds age- and sex-specific per capita expenditures constant. METHODS: We used a longitudinal hospital dataset which followed 90 929 patients aged 65 and older from 1970 to death, to create an economic model of hospital costs based on patient age and time remaining to death. We then applied the model to England population projections to predict the effect of demographic changes on hospital expenditures from 2002 to 2026. RESULTS: The decline in age-specific mortality rates over time postpones death to later ages, pushing back death-related costs. Accounting for this in expenditure projections gave a predicted annual growth rate of 0.40%-half of the rate predicted with a traditional method. CONCLUSIONS: Using richer data and more refined methods than have hitherto been employed, this study strongly confirms that the pressure of population increases and ageing demographic structure on hospital expenditures will be partially countered by the postponement of death-related hospital costs to later in life-a finding consistent with emerging epidemiological evidence, and heartening for policy makers and physicians alike.     

A longitudinal study of the effects of age and time to death on hospital costs

Recent studies indicate that approaching death, rather than age, may be the main demographic driver of health care costs. Using a 29-year longitudinal English dataset, this paper uses more robust methods to examine the effects of age and proximity to death on hospital costs. A random effects panel data two-part model shows that approaching death affects costs up to 15 years prior to death. The large tenfold increase in costs from 5 years prior to death to the last year of life overshadows the 30% increase in costs from age 65 to 85. Hence, expenditure projections must consider remaining life expectancy in the populations.     

Did postoperative mortality increase after the implementation of the Medicare Balanced Budget Act?

BACKGROUND: The Balanced Budget Act (BBA) of 1997 was a cost-saving measure designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. Resulting financial strain could adversely affect the quality of patient care in hospitals. OBJECTIVE: We sought to determine whether 30-day mortality rates for surgical patients who developed complications changed at different rates in hospitals under different levels of financial strain from the BBA. METHODS: Pennsylvania hospital discharge data, financial data, and death certificate data from 1997 to 2001 were obtained. A retrospective multivariate analysis examined whether 30-day mortality rates from 8 postoperative complications varied based on degree of hospital financial strain. RESULTS: The average magnitude of Medicare payment reduction on overall hospital net revenues was estimated at 1.8% for hospitals with low BBA impact and 3.5% for hospitals with high impact in 1998, worsening to 2.0% and 4.8%, respectively, by 2001. Mortality rates changed at similar rates for high- and low-impact hospitals from 1997 to 1999, but from 1997 to 2000 mortality rates increased more among patients in high-impact compared with low-impact hospitals (P<0.05). From 2000 to 2001, mortality rates among impact groups converged. There were no statistically significant differences based on BBA impact in changes in nursing staff or length of stay. CONCLUSIONS: The mortality of surgical patients who developed postoperative complications increased to a greater degree in the short term in hospitals affected more by BBA. Measuring the quality impact of reimbursement cuts is necessary to understand cost-quality tradeoffs that may accompany cost-saving reforms.     

Is clozapine cost-effective?

The treatment of schizophrenia accounts for approximately 2.5% of national healthcare expenditures, with the majority of this expense concentrated on costly in-patient services. Health policy leaders have expressed concern that these costs create a strain on limited resources. Newer antipsychotic pharmacotherapies, such as clozapine (Clozaril, Leponex; Novartis), may improve patient symptoms and potentially lower hospital use. However, the high cost of these pharmaceutical treatments must be considered alongside any savings in hospital costs and improvement in patient functioning, when assessing the overall economic impact of using such treatment on schizophrenic patients. This review examines six key cost-effectiveness studies that address the economic considerations and quality-of-life issues associated with the use of clozapine in battling the burdens of schizophrenia to determine whether in fact the use of clozapine is clinically and economically appropriate. As such, the review suggests: (a) treatment with clozapine significantly improves patient symptoms and quality of life; (b) patients who receive clozapine experience a reduction in the number of hospitalizations, which can lead to a decrease in hospital costs; (c) treating patients with clozapine shifts the cost structure from in-patient care to outpatient care and drug therapies; and (d) patients who receive clozapine can experience a reduction in overall treatment costs. However, several cost considerations remain unaccounted in most studies, and a serious effort is needed to conduct studies of the vast numbers of outpatients who might benefit from treatment with clozapine.     

Cymetra injections to treat leakage around a tracheoesophageal puncture

Tracheoesophageal puncture (TEP) is a commonly used method of voice restoration following total laryngectomy, but leakage around the prosthesis is prevalent. Several treatments for leakage have been proposed in the literature, but with varying success. This paper examines the efficacy of Cymetra to help shrink the TEP site and stop leakage. Six patients with leaking TEP sites refractory to downsizing and/or cautery were selected for the study. Injection sites were determined based on the primary sites of leakage. Cymetra was rehydrated with 1.0 % lidocaine saline solution and injected via a 23-gauge needle a few millimeters deep to the mucosa, approximately 2 mm from the edge. The patients were followed for up to 13 months. Following 1 trial of Cymetra injection, 4 patients achieved successful results. Only 1 patient has not yet achieved full resolution of leakage. Cymetra may provide a safer and more effective option for resolution of leakage than other methods currently employed.     

Detecting default mode networks in utero by integrated 4D fMRI reconstruction and analysis

Recently, there has been considerable interest, especially for in utero imaging, in the detection of functional connectivity in subjects whose motion cannot be controlled while in the MRI scanner. These cases require two advances over current studies: (1) multiecho acquisitions and (2) post processing and reconstruction that can deal with significant between slice motion during multislice protocols to allow for the ability to detect temporal correlations introduced by spatial scattering of slices into account. This article focuses on the estimation of a spatially and temporally regular time series from motion scattered slices of multiecho fMRI datasets using a full four‐dimensional (4D) iterative image reconstruction framework. The framework which includes quantitative MRI methods for artifact correction is evaluated using adult studies with and without motion to both refine parameter settings and evaluate the analysis pipeline. ICA analysis is then applied to the 4D image reconstruction of both adult and in utero fetal studies where resting state activity is perturbed by motion. Results indicate quantitative improvements in reconstruction quality when compared to the conventional 3D reconstruction approach (using simulated adult data) and demonstrate the ability to detect the default mode network in moving adults and fetuses with single‐subject and group analysis. Hum Brain Mapp 37:4158–4178, 2016. © 2016 Wiley Periodicals, Inc.     

Ageing and health-care expenditure: the red herring argument revisited

Zweifel and colleagues have previously proposed that proximity to death is a more important influence on health-care costs than age, suggesting that demographic change per se will not have a large impact on future aggregate health expenditure. However, issues of econometric methodology have led to challenges of the robustness of these findings. This paper revisits the analysis. Using a longitudinal hospital data set from Oxfordshire, England, the two-step Heckman model from the Zweifel study is first replicated, to find that neither age nor proximity to death have a significant effect on hospital costs. Econometric problems with the model are demonstrated, and instead a two-part model shows both age and proximity to death to have significant effects on quarterly hospital costs. Cost predictions, calculated with bootstrapped 95% confidence intervals, further demonstrate that while age may significantly affect quarterly costs, these cost changes are small compared to the tripling of quarterly costs that occurs with approaching death in the last year of life. The analyses show the importance of model selection to properly assess the determinants of health-care expenditures.     

The impact of ageing on expenditures in the National Health Service

BACKGROUND: health policy makers in many countries have expressed concern over the pressures that increased numbers of older people will exert on health care costs. Previous studies have shown that, in addition to increasing size of older populations, per capita expenditures have risen disproportionately among the old compared to the middle age groups. Documentation of such trends is essential for more accurate projection of health expenditures. OBJECTIVE: we examined detailed national age-specific expenditure trends for England and Wales, comparing findings with Canada, Japan, and Australia. METHODS: we obtained total health expenditures for each age group from the UK Department of Health for time periods 1985-87 to 1996-99. We examined changes in age-specific per capita expenditure, population demographics, and the allocation of national expenditures to the different age groups. We then determined the association of changes in population, age structure, and age-specific per capita expenditure to increases in national health care expenditure for England and Wales, comparing results to Canada, Japan, and Australia. RESULTS: per capita health expenditures in England and Wales increased by 8% for ages 65 and over, compared to 31% for ages 5-64. Hence the proportion of total expenditures allocated to the population aged 65 and over decreased from 40% to 35%, a trend most noticeable for non-acute hospital costs. Demographic shifts and population growth accounted for only 18% of the observed increases in health care expenditures in England and Wales, compared to 68%, 44%, and 34% in Japan, Canada, and Australia respectively. CONCLUSIONS: in contrast to other countries, England and Wales had slower rises in per capita costs and a decreasing proportion of national expenditures allocated to older people. These differences invite future research into the actual demand drivers of these costs.