Source: Centers for Medicare and Medicaid Services (HHS)
Today, as part of the Obama administration’s work to make our health care system more affordable and accountable, Health and Human Services (HHS) Secretary Kathleen Sebelius announced a three-part initiative that for the first time gives consumers information on what hospitals charge. New data released today show significant variation across the country and within communities in what hospitals charge for common inpatient services. Also today, HHS made approximately $87 million available to states to enhance their rate review programs and further health care pricing transparency. In an example of how these data might be used, the Robert Wood Johnson Foundation (RWJF) is planning a data visualization challenge which will further the dissemination of these data to larger audiences.
“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said. “This data and new data centers will help fill that gap.”
The data posted today on CMS’s website include information comparing the charges for services that may be provided during the 100 most common Medicare inpatient stays. Hospitals determine what they will charge for items and services provided to patients and these “charges” are the amount the hospital generally bills for an item or service.
“How Much Will I Get Charged for This?” Patient Charges for Top Ten Diagnoses in the Emergency Department
We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED).
We conducted a cross-sectional study of the 2006–2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18–64) patients with a single discharge diagnosis.
We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651–$817) for an upper respiratory infection to $3437 (95% CI $2917–$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199– $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550.
Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.
Source: U.S. Department of Health and Human Services, Office of Inspector General
WHY WE DID THIS STUDY
A recent nationwide meningitis outbreak caused by contaminated injections, which were compounded by the New England Compounding Center, raised major concerns about the use of drugs supplied by compounding pharmacies. Hospitals may have sourcing arrangements with multiple outside compounding pharmacies and may also compound drugs within their own pharmacies. The meningitis outbreak and its aftermath revealed a gap in information about hospitals’ use of compounded drugs supplied by outside pharmacies and the steps that hospitals take to ensure the quality of compounded drugs.
HOW WE DID THIS STUDY
This study focused on hospital use of compounded sterile preparations (CSPs). CSPs are sterile compounded drugs that are generally administered to patients via injection or infusion. We surveyed a nationally representative sample of 298 acute-care hospitals operating in 2012 that participated in Medicare. We developed and used an online questionnaire to determine the extent and nature of hospital use of CSPs and outsourcing, including the extent to which hospitals outsource versus prepare onsite, and challenges in outsourcing and preparing CSPs. We received responses from 236 hospitals, an overall response rate of 79 percent. In addition, we interviewed stakeholders, including four practicing hospital pharmacists and officials of the trade association that represents hospital pharmacists.
WHAT WE FOUND
In 2012, 92 percent of hospitals used CSPs. Almost all hospitals (92 percent) used sterile-to-sterile CSPs and only 25 percent of hospitals used higher risk nonsterile-to-sterile products. Of the hospitals that used nonsterile-to-sterile CSPs, 85 percent outsourced at least some of these products (i.e., purchased them from outside pharmacies). Factors related to ensuring an adequate supply of CSPs were very important to hospitals when determining whether to outsource CSPs. Also, hospitals took limited steps to ensure the quality of outsourced CSPs but had few problems with the quality of products from outside pharmacies. Finally 56 percent of hospitals made changes or planned to make changes to CSP sourcing practices in response to the fall 2012 meningitis outbreak.
This report does not contain recommendations. OIG will pursue additional work to further examine the safety and quality of pharmaceutical compounding in hospitals, including work examining Federal oversight mechanisms.
Source: National Center for Health Statistics
Data from the National Hospital Discharge Survey, 2000–2010
- The number of inpatient hospital deaths decreased 8%, from 776,000 in 2000 to 715,000 in 2010, while the number of total hospitalizations increased 11%.
- In 2000, 2005, and 2010, about one-quarter of inpatient hospital deaths were for patients aged 85 and over.
- Hospital death rates declined overall from 2000 to 2010 but increased 17% for septicemia.
- Patients who died in the hospital had longer hospital stays than all patients. In 2010, those who died stayed an average of 7.9 days compared with 4.8 days for all patients.
- In 2000, there were 2.4 million deaths in the United States, and in 2010 there were 2.5 million (1,2). In both years, about one-third of these deaths occurred in short-stay, general hospitals (3), despite research that found that most Americans prefer to die in their own homes (4–6). This report presents National Hospital Discharge Survey (NHDS) data from 2000 through 2010 on patients who died during hospitalization.
Source: New England Journal of Medicine
On December 4, 2012, two Australian radio DJs called London’s King Edward VII’s Hospital, identified themselves, in fake British accents, as Queen Elizabeth and Prince Charles, and asked about a celebrity patient who had been admitted for pregnancy complications. A nurse, filling in at the reception desk in the early morning hours, answered the phone and, without attempting to verify the callers’ identities, transferred them to the duty nurse caring for the Duchess of Cambridge. The duty nurse then provided them with confidential patient information.1 The Australian DJs broadcast the phone call, considering it a humorous prank, but as the world knows, it had disastrous consequences.
How confident are U.S. hospitals, nursing homes, and physicians’ offices that their staff would appropriately deny patient information to an unknown caller?
Vital Signs: Carbapenem-Resistant Enterobacteriaceae
Source: Morbidity and Mortality Weekly Report (CDC)
Background: Enterobacteriaceae are a family of bacteria that commonly cause infections in health-care settings as well as in the community. Among Enterobacteriaceae, resistance to broad-spectrum carbapenem antimicrobials has been uncommon. Over the past decade, however, carbapenem-resistant Enterobacteriaceae (CRE) have been recognized in health-care settings as a cause of difficult-to-treat infections associated with high mortality.
Methods: The percentage of acute-care hospitals reporting at least one CRE from health-care–associated infections (HAIs) in 2012 was estimated using data submitted to the National Healthcare Safety Network (NHSN) in 2012. The proportion of Enterobacteriaceae infections that were CRE was calculated using two surveillance systems: 1) the National Nosocomial Infection Surveillance system (NNIS) and NHSN (for 2001 and 2011, respectively) and 2) the Surveillance Network–USA (TSN) (for 2001 and 2010). Characteristics of CRE culture-positive episodes were determined using data collected as part of a population-based CRE surveillance project conducted by the Emerging Infections Program (EIP) in three states.
Results: In 2012, 4.6% of acute-care hospitals reported at least one CRE HAI (short-stay hospitals, 3.9%; long-term acute-care hospitals, 17.8%). The proportion of Enterobacteriaceae that were CRE increased from 1.2% in 2001 to 4.2% in 2011 in NNIS/NHSN and from 0% in 2001 to 1.4% in 2010 in TSN; most of the increase was observed in Klebsiella species (from 1.6% to 10.4% in NNIS/NHSN). In the EIP surveillance, 92% of CRE episodes occurred in patients with substantial health-care exposures.
Conclusions: Carbapenem resistance among common Enterobacteriaceae has increased over the past decade; most CRE are associated with health-care exposures.
Implications for Public Health: Interventions exist that could slow the dissemination of CRE. Health departments are well positioned to play a leading role in prevention efforts by assisting with surveillance, situational awareness, and coordinating prevention efforts.
Source: Agency for Healthcare Research and Quality
Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization. Research shows that close to one-third of falls can be prevented. Fall prevention involves managing a patient’s underlying fall risk factors and optimizing the hospital’s physical design and environment. This toolkit focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program.
Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure
Source: Archives of Internal Medicine (JAMA Internal Medicine)
Many proposals for health care reform incentivize patients to play a more active role in selecting health care providers on the basis of quality and price. While data on quality are increasingly available, availability of pricing data is uncertain.
To examine whether we could obtain pricing data for a common elective surgical procedure, total hip arthroplasty (THA).
We randomly selected 2 hospitals from each state (plus Washington, DC) that perform THA, as well as the 20 top-ranked orthopedic hospitals according to US News and World Report rankings. We contacted each hospital by telephone between May 2011 and July 2012. Using a standardized script, we requested from each hospital the lowest complete “bundled price” (hospital plus physician fees) for an elective THA that was required by one of the author’s 62-year-old grandmother. In our scenario, the grandmother did not have insurance but had the means to pay out of pocket. We explained that we were seeking the lowest complete price for the procedure. When we encountered hospitals that could provide the hospital fee only, we contacted a random hospital affiliated orthopedic surgery practice to obtain the physician fee. Each hospital was contacted up to 5 times in efforts to obtain pricing information.
All top-ranked and a sample of non–top-ranked US hospitals performing THA.
Main Outcome Measures
Percentage of hospitals able to provide a complete price estimate for THA (physician and hospital fee) for top-ranked and non–top-ranked hospitals and range of prices quoted by each group.
Nine top-ranked hospitals (45%) and 10 non–top-ranked hospitals (10%) were able to provide a complete bundled price (P < .001). We were able to obtain a complete price estimate from an additional 3 top-ranked hospitals (15%) and 54 non–top-ranked hospitals (53%) (P = .002) by contacting the hospital and physician separately. The range of complete prices was wide for both top-ranked ($12 500-$105 000) and non–top-ranked hospitals ($11 100-$125 798).
Conclusions and Relevance
We found it difficult to obtain price information for THA and observed wide variation in the prices that were quoted. Many health care providers cannot provide reasonable price estimates. Patients seeking elective THA may find considerable price savings through comparison shopping.
Source: Robert Wood Johnson Foundation
Leaving the hospital sounds simple. But all too often, people find themselves back at the hospital within only a few weeks. With better planning and better communication, many of these return visits can be avoided. This fact sheet from Care About Your Care can help patients take steps to avoid being readmitted.
- Ask and ask again
- Say it back
- Have a discharge plan
- Manage your medications
- Keep appointments
- Know what to do if you don’t feel well
Source: U.S. Department of Health and Human Services, Office of Inspector General
The Department of Health & Human Services (HHS) Office of Inspector General (OIG) Compendium of Unimplemented Recommendations (Compendium) summarizes significant1 monetary and nonmonetary recommendations that, when implemented, will result in cost savings and/or improvements in program efficiency and effectiveness. The recommendations result from audits and evaluations that are performed pursuant to the Inspector General Act of 1978, as amended.
Source: Health Care Law Monthly
As demonstrated by news events this year, hospitals are unfortunately not immune to the risks of weapons or contraband being brought onto hospital premises. In just one month this year (June 2012), the media reported three separate hospital incidents. First, in Texas, a former patient entered a hospital emergency department allegedly demanding pain killers. When his request was denied, he reportedly took several hospital staff members hostage at gunpoint. The police arrived at the hospital but negotiations with the gunman proved unsuccessful; he was shot and killed by police. That same month, in New York, a surgeon allegedly brought a gun to the hospital where he worked and killed a hospital receptionist. The surgeon later reportedly committed suicide. Also in June 2012, a British hospital patient was reportedly found with illegal drugs. Hospital staff suspected the patient was taking the drugs after observing him behave erratically. The patient was later charged with possession of illegal drugs. As described by The Joint Commission in a Sentinel Event Alert, hospitals were once considered ‘‘safe havens’’ but ‘‘as criminal activity spills over from the streets onto the campuses and through the doors,’’ hospitals face particular challenges in securing the building and grounds ‘‘[b]ecause hospitals are open to the public around the clock every day of the year.’’ These challenges are especially difficult in hightraffic areas which have high-stress levels, such as the emergency department.
This article summarizes the analysis used by courts in assessing searches conducted of hospital patients, their rooms and their belongings–whether in the Emergency Department or elsewhere at a hospital. Most of the caselaw in this area involves criminal defendants challenging a search conducted while they were hospital patients. Many cases involve police or state hospital staff performing the searches and thus involve the Fourth Amendment right of protection from unreasonable search and seizure. Courts have also addressed private searches, e.g., searches conducted by members of a private hospital’s staff rather than the police. Both types of cases offer valuable insight into the type and scope of permitted searches at hospitals.
Impact of emergency medical helicopter transport directly to a university hospital trauma center on mortality of severe blunt trauma patients until discharge
Source: Critical Care
The benefits of transporting severely injured patients by helicopter remains controversial. This study aimed to analyze the impact on mortality of helicopter compared to ground transport directly from the scene to a University hospital trauma center.
The French Intensive Care Research for Severe Trauma cohort study enrolled 2703 patients with severe blunt trauma requiring admission to University hospital intensive care units within 72 hours. Pre-hospital and hospital clinical data including the mode of transport, helicopter (HMICU) vs ground (GMICU), both with medical teams, were recorded. The analysis was restricted to patients admitted directly from the scene to a University hospital trauma center. The main endpoint was mortality until ICU discharge.
Of the 1958 patients analyzed, 74% were transported by GMICU, 26% by HMICU. Median ISS was 26 (IQR 19-34) for HMICU patients and 25 (IQR 18-34) for GMICU patients. Compared to GMICU, HMICU patients had a higher median time frame before hospital admission and were more intensively treated in the pre-hospital phase. Crude mortality until hospital discharge was the same regardless of pre-hospital mode of transport. After adjustment for initial status, the risk of death was significantly lower (OR: 0.68, 95% CI 0.47-0.98, p=0.035) for HMICU compared with GMICU. This result did not change after further adjustment for ISS and overall surgical procedures.
This study suggests a beneficial impact of helicopter transport on mortality in severe blunt trauma. Whether this association could be due to better management in the pre-hospital phase needs to be more thoroughly assessed.
Source: New England Journal of Medicine
Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries.1 Although much attention has been paid to increasing ED use, the ED’s changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter of all acute care outpatient visits in the United States occur in EDs, a proportion that has been growing since 2001.2 We examined the proportion of hospital admissions that come through the ED, hypothesizing that use of the ED as the admission portal had increased across conditions.
We analyzed data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the most recent year for which the ED admission data are available on HCUPnet, an interactive Web-based tool that uses data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality). The NIS contains data from approximately 8 million hospital stays each year and is weighted to produce national estimates. We used HCUPnet to query the NIS regarding trends in the 20 clinical conditions for which patients were most frequently admitted to the hospital in 2006. Clinical Classifications Software was used to group the conditions into clinically meaningful categories. We excluded two conditions for which patients are rarely admitted through the ED (osteoarthritis and back problems), one psychiatric condition that was not consistently coded in claims data (affective disorder), and four obstetrical diagnoses that are generally evaluated in other care settings, such as labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other complications of birth, other complications of pregnancy).
The number of hospital admissions increased by 15.0%, from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient stays involving admission from the ED increased from 33.5 to 43.8% (P<0.001). In 12 of the 13 conditions for which patients were most frequently admitted and that met our inclusion criteria, an increased proportion of admitted patients came through the ED (P<0.001), regardless of the trend in overall admissions; the exception was coronary atherosclerosis, for which rapid “rule-out” protocols and ED-based chest-pain observation units have reduced the need for inpatient admission.
Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009
Source: Morbidity and Mortality Weekly Report (CDC)
Deep vein thrombosis (DVT) is a blood clot that occurs in a deep vein of the body; pulmonary embolism (PE) occurs when a clot breaks free and enters the arteries of the lungs. DVT and PE comprise venous thromboembolism (VTE), an important and growing public health concern (1,2). Hospitalization is a major risk factor for VTE, and many VTE events that occur among hospitalized patients can be prevented (2,3). A new program of the U.S. Department of Health and Human Services (Partnership for Patients: Better Care, Lower Costs) aims to reduce the number of preventable VTE cases in hospitals (4). To estimate the number of hospitalizations with VTE each year in the United States, CDC analyzed 2007–2009 data from the National Hospital Discharge Survey (NHDS). The results of that analysis determined that an estimated average of 547,596 hospitalizations with VTE occurred each year among those aged ≥18 years in the United States. DVT was diagnosed in an estimated annual average of 348,558 hospitalizations, and PE was diagnosed in 277,549; both DVT and PE were diagnosed in 78,511 hospitalizations. Estimates of the rates of hospitalizations with VTE were substantially higher among adults aged ≥60 years compared with those aged 18–59 years. These findings underscore the need to promote implementation of evidence-based prevention strategies to reduce the number of preventable cases of VTE among hospitalized patients.
Dates of Support: 1999–2011Field of Work: Palliative and end-of-life careProblem Synopsis: Advances in public health, preventive medicine, and medical technology have led to dramatic increases in the number of Americans living longer. While many people over age 65 enjoy good health for some time, eventually most adults will have one or more chronic illnesses often characterized by pain and frailty. The nation’s health care system is not well suited to address the array of medical, social, emotional, and other needs of patients living for long periods with serious, but not immediately terminal, conditions.Synopsis of the Work: During 1999–2011, the Center to Advance Palliative Care (CAPC) at the Mount Sinai School of Medicine undertook a range of initiatives to increase the number of hospitals able to provide palliative care, make hospital-based palliative care standard practice, and develop standards for palliative care programs.To achieve these goals, CAPC selected and supported nine Palliative Care Leadership Centers (six funded by RWJF) based at hospitals across the country, led a consortium of organizations in developing consensus standards of palliative care, and demonstrated cost savings attributable to palliative care. In addition, CAPC provided ongoing in-person and online resources, and training via national seminars, audio grand rounds, and guidebooks.Key Results: CAPC developed a new understanding of palliative care that shaped the thinking of physicians, patients, and policy-makers. By distinguishing palliative care from end-of-life or hospice care, CAPC expanded its audience to include patients with serious, but not immediately life-threatening, conditions. Physicians and their patients could work simultaneously on providing care aimed at both curing the condition and ensuring that patients were comfortable and stable.
- By 2009, the number of hospitals providing palliative care increased by 138 percent, from 658 to 1,568.
- The Palliative Care Leadership Centers had trained 1,029 teams from hospitals across the country, 80 percent of which had established their own palliative care programs within two years.
- In 2006, the National Quality Forum endorsed a framework for preferred practices in palliative and hospice care. In 2011, the Joint Commission launched a Palliative Care Advanced Certification program.
A team from RAND and the University HealthSystem Consortium developed a toolkit to help hospitals enhance their quality improvement efforts using quality indicators from the Agency for Healthcare Research and Quality.
In the 30 days after hospital discharge, hospital utilisation is common and costly. This study evaluated the association between gender and hospital utilisation within 30 days of discharge.Design:
Secondary data analysis using Poisson regression stratified by gender.Participants:
737 English-speaking hospitalised adults from general medical service in urban, academic safety-net medical centre who participated in the Project Re-Engineered clinical trial (clinicaltrials.gov identifier: NCT00252057).Main outcome measure:
The primary end point was hospital utilisation, defined as total emergency department visits and hospital readmissions within 30 days after index discharge.Results:
Female subjects had a rate of 29 events for every 100 people and male subjects had a rate of 47 events for every 100 people (incident rate ratio (IRR) 1.62, 95% CI 1.28 to 2.06). Among men, risk factors included hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.55, 95% CI 2.38 to 5.29), being unmarried (IRR 1.72, 95% CI 1.12 to 2.64), having a positive depression screen (IRR 1.53, 95% CI 1.09 to 2.13) and no primary care physician (PCP) visit within 30 days (IRR 1.64, 95% CI 1.08 to 2.50). Among women, the only risk factor was hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.08, 95% CI 1.86 to 5.10).Conclusions:
In our data, male subjects had a higher rate of hospital utilisation within 30 days of discharge than female subjects. For men—but not for women—risk factors were being retired, unmarried, having depressive symptoms and having no PCP visit within 30 days. Interventions addressing these factors might lower hospital utilisation rates observed among men.
So you want kids, do you? At the Ecologist, we’re not going to preach about the impending population bomb, and its devastating impact on scarce resources and the earth’s changing climate. At least, not for now. No, we want to talk about the joys of having children. Becoming a parent is the beginning of the roller coaster ride of a lifetime. But when the thrill is gone, we’re left with worry and white knuckles. Childbirth, one of life’s most empowering experiences, has been hijacked. It’s become institutionalised, taken over by technology, exiled from communities into hospitals and overhyped on TV dramas by scare-mongering pundits.As we don’t see it happening in our daily lives – around two per cent of births in England are home births – it is no longer part of our communities. This means that, especially for women, what we know about childbirth, before we experience it ourselves, is through stories. And stories are primarily about fear.
On February 16, 2012, the Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced that “HHS will initiate a process to postpone the date” by which certain health care entities have to comply with ICD-10. While there is uncertainty on a new compliance date, the transition to the ICD-10 coding set presents opportunities, benefits, and challenges that providers should address whether the implementation date is set for 2013, 2014, or beyond.
As organizations review their implementation plans based on scenarios that could play out with an extension, leaders of hospitals and medical groups should keep in mind that regardless of the compliance date, the transition to ICD-10 requires extensive planning and coordination across the organization. Organizations that have completed their ICD-10 readiness assessments have discovered that the road forward presents enterprise-wide challenges that require both a strategic and tactical solution if they plan to leverage benefits from the transition.
This article explores strategic decisions and leading practices for ICD-10 implementation across four key areas: project governance, technology, finance, and operations.
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