Published in the July 2015 issue of Today’s Hospitalist
Another year of doc payment data
FOR THE SECOND YEAR in a row, the CMS has released a year’s worth of data on physician payments, this time for 2013. The data were released in June.
According to a Bloomberg Business analysis, the CMS in 2013 paid at least $1 million each to 3,900 doctors, while five physicians each received more than $10 million. On average, individual physician reimbursement from Medicare in 2013 came in at about $74,000.
The CMS also released its third year of hospital payment data, making it possible to see trends in inpatient payments. For the No. 1 discharge diagnosis, major joint replacement, the CMS in 2011 paid hospitals $50,116. That amount had grown 8.2% by 2013 to $54,239.
In 2013, the top 100 most common inpatient stays for Medicare patients were associated with nearly $62 billion in Medicare payments and more than 7 million hospital discharges.
Hospital markups gone wild
A NEW STUDY names 50 hospitals with the dubious distinction of having the country’s most extreme charge-to-cost ratios.
While most hospitals mark up their Medicare-allowable costs by a factor of 3.4, charges for the hospitals that made the top 50 list are about 10 times higher than allowable costs. Only one of the 50 hospitals is a nonprofit, and 40% are located in Florida. No. 1 is North Okaloosa Medical Center in Crestview, Fla.
While most insurers negotiate lower charges, uninsured patients or out-of-network patients, along with workers’ comp and casualty insurers, are more likely to be asked to pay full freight. The study appeared in the June issue of Health Affairs.
The authors suggested that the government should limit charge-to-cost ratios or mandate price disclosures. But in statements quoted by HealthLeaders Media, several of the hospital systems represented on the list noted that very few patients are billed those marked-up charges and that the hospitals deliver considerable amounts of uncompensated care.
Who does periop beta-blockade help, hurt?
DO PATIENTS benefit from periop beta-blockade in noncardiac surgery? It depends on their individual cardiac risk factors, according to a retrospective HealthLeaders Media that looked at data for more than 326,000 VA patients.
Cardiac risk factors included coronary artery disease, diabetes, renal failure and major body cavity surgery. Patients with no cardiac risk factors had a 19% higher risk of death with perioperative beta-blockers. That’s the first time that finding has been reported, according to the authors, in large part because the new analysis examined a much larger number of patients than previous studies.
Further, researchers found that beta-blockade appeared to have no effect on patients with only one or two risk factors. But patients with three or four risk factors were found to have a 37% reduction in 30-day mortality with periop beta-blockade vs. no beta-blockers.
The study noted that the use of perioperative beta-blockade across different risk categories has been the subject of “persistent controversy.” Study results were posted online in May by JAMA Surgery.
S. aureus bundle cuts surgical site infections
AN EVIDENCE-BASED BUNDLE to screen and treat select surgical patients for MRSA and MSSA reduced complex S. aureus surgical site infections by 40%.
The bundle, which was implemented in 20 hospitals across nine states, consisted of getting preop nasal samples for patients undergoing cardiac surgery or hip or knee replacement. Patients who tested positive for MRSA or MSSA applied intranasal mupirocin twice daily and bathed once a day with chlorhexidine for up to five days before surgery.
In addition, MRSA carriers received perioperative prophylaxis of vancomycin and cefazolin or cefuroxime. MSSA carriers and noncarriers received cefazolin or cefuroxime. Results appeared in the June 2 issue of the Journal of the American Medical Association.
Infection rates were reduced among patients who received all bundle elements, but not among those receiving only some or none. The authors noted that bundle adherence was much higher during elective surgeries than for urgent or emergent procedures. They also pointed out that each surgical site infection can add between $13,000 and $100,000 in health care costs.
Low-risk chest pains should be discharged home
PATIENTS WHO PRESENT to EDs with chest pain are routinely admitted to be observed or treated, even when they have negative troponins, stable vital signs and nonischemic EKGs. But that strategy is costly and unnecessary, according to a study posted online in May by JAMA Internal Medicine.
Researchers analyzed patients who presented with chest pain to one of three EDs over five years; each of those patients had two negative troponins. Among more than 7,200 patients, there were only four adverse events of patients who died in the short term or suffered a life-threatening arrhythmia, inpatient STEMI, or cardiac or respiratory arrest. Two of those events, authors wrote, were “possibly iatrogenic.”
Instead of being admitted or placed in observation, the authors claimed, patients would be better off with swift outpatient follow-up. “Our findings support the notion,” they wrote, “that adverse iatrogenic events as a result of admission may eclipse potential benefits in low-risk patients.”
Sepsis risk jumps with hospitalizations, infections
AFTER EXAMINING DATA on more than 11,000 Medicare patients, researchers have found that patients are at the highest risk of developing severe sepsis within 90 days of being discharged from a hospital. That three-month risk is 30% higher for patients who were treated in the hospital for any type of infection and 70% higher for patients who had been infected with C. diff.
The adjusted probabilities of subsequent severe-sepsis admission within 90 days were 4.1% for non-infection-related index hospital stays, 7.1% for infection-related hospital stays and 10.7% for patients with C. diff during their index hospitalization. One in 10 C. diff survivors goes on to develop severe sepsis within three months, the authors wrote.
Study results were published online in May by the American Journal of Respiratory and Critical Care Medicine. The findings, authors noted, could indicate that microbiome disruption may predispose patients to severe sepsis.
Low marks for the Wells score
HOW RELIABLE is the Wells score in the hospital to rule out DVT or help guide patient management? Not at all, according to a new study in which authors claim that the Wells score “performed only slightly better than chance” among inpatients.
The study looked at 1,135 patients who underwent lower-extremity venous duplex ultrasound. Among those patients, 12.1% were found to have a proximal DVT. However, the Wells score for those patients had a much higher failure rate and lower efficiency than researchers have found when using the Wells score among outpatients. Results were posted online in May by JAMA Internal Medicine.
The authors noted that possible explanations include the much higher incidence of comorbidities, cancers, surgical procedures and immobility among hospitalized patients. However, the authors of a related editorial wrote that they do rely on the negative predictive value of combining a Wells score with D-dimer testing.
How to resolve patient disputes in the ICU
THE AMERICAN THORACIC SOCIETY has issued new recommendations to prevent and manage intractable conflicts over life-extending treatments in the ICU.
In a new policy statement, the medical society suggested that physicians can head off such conflicts with patients or surrogates through early and intensive communication and by relying on expert consults. Once conflicts arise, those should be managed by seeking second medical opinions and interdisciplinary committee review.
For disputes that can’t be resolved, the policy statement recommended ongoing mediation, offering patients or surrogates the opportunity to transfer to another facility, and informing families of their right to appeal in court.
The statement also noted that physicians should not use the word “futile” to describe treatments that doctors feel are not warranted. Instead, they should characterize such treatments as “potentially inappropriate.” The statement was published in the June 1 issue of the American Journal of Respiratory and Critical Care Medicine.
Boosting weekend care delivers big LOS payoff
A SUITE OF INTERVENTIONS that significantly increased a hospital’s weekend staffing and services cut average length of stay and increased the proportion of patients being discharged on the weekend.
Researchers at New York’s NYU Langone Medical Center did a before-and-after analysis of several interventions that expanded diagnostic services on weekends, improved weekend discharge processes, and boosted both hospitalist and care management weekend services.
The hospital’s average length of stay fell 13% and continued to fall 1% a month. At the same time, the percentage of patients being discharged on the weekend rose 12% and continued to increase 2% per month. However, researchers found that boosting weekend staffing and resources had no impact on readmission or mortality rates.
Results were published in the May issue of the Journal of General Internal Medicine. The authors noted that standard weekend hospital care has been associated in other research with care delays, lower quality and worse outcomes.
Time to shut down low-volume surgeons?
SEVERAL HEALTH SYSTEMS have urged U.S. hospitals to follow their lead and not allow surgeons to do any of 10 procedures unless surgeons perform a certain number of those surgeries every year.
The health systems “Dartmouth-Hitchcock, Johns Hopkins and the University of Michigan “recommended annual volume thresholds for those procedures, which include hip and knee replacement, bariatric surgery, and carotid artery stenting. One option, according to an initiative leader, would be to tie surgeons’ hospital privileges to surgical volumes.
According to HealthLeaders Media coverage, the use of such thresholds would stop surgeons who now perform those procedures in half of all U.S. hospitals. However, only 15% of patients undergoing those procedures would need to be redirected to other facilities because those surgeons’ volume is so low.
The initiative was announced at the same time that U.S. News & World Report published an article on the “unmistakable” risks of surgeries in very low volume hospitals.