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Background: In response to the declining utilization and patient revenue due to the COVID-19 pandemic, the U.S. hospital industry furloughed at least 1.4 million health care workers to contain their clinical-related expenses. However, it remains unclear how hospitals responded by adjusting their administrative expenses, which account for more than a quarter of U.S. hospitals' spending, a proportion substantially higher than that of other industrialized countries. Examining changes in hospitals' administrative expenses during the COVID-19 pandemic is important for understanding hospitals' cost-containment behaviors under operational shocks during a pandemic., Objective: To assess changes in hospitals' administrative expenses and clinical expenses during the COVID-19 pandemic in 2020., Design: Time-series observational study., Participants: 1420 Medicare-certified general acute-care hospitals with fiscal years starting in January and continuously operating during 2016-2020., Main Measures: Hospitals' annual administrative expenses and clinical expenses., Key Results: Hospitals' median administrative and clinical expenses both increased consistently around 4% each year from 2016 to 2019. From 2019 to 2020, the median administrative expenses grew by 6.2% while the median clinical expenses grew by 0.6%. The interrupted time-series regression estimated an additional 6.4% (95% CI, 4.5 to 8.2%) increase in administrative expenses in 2020, relative to the pre-COVID annual increase of 3.9% (95% CI, 3.3 to 4.4%), while an additional increase in clinical expenses in 2020 (0.5%; 95% CI, -0.3 to 1.4%) did not differ from the pre-COVID annual increase of 3.7% (95% CI, 3.5 to 4%). Stratified analysis showed hospitals with larger utilization volume, located in states with lower COVID-19 burden, or situated in counties with higher median household income experienced larger increase in administrative expenses in 2020., Conclusions: In 2020, administrative expenses grew much faster than clinical expenses, resulting in a larger share of hospital financial resources allocated to administrative activities. Higher administrative expenses might reflect hospitals' operational effort in response to the pandemic or inefficient cost management., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Using bargaining agreement data from the Federal Mediation Conciliation Services, we found that the median national resident COVID-19 mortality percentage (as of April 24, 2022) of unionized nursing homes and that of nonunionized ones were not statically different (10.2% vs. 10.7%; P = 0.32). The median nursing home resident COVID-19 mortality percentage varied from 0% in Hawaii to above 16% in Rhode Island (16.6%). Unionized nursing homes had a statistically significant lower median mortality percentage than nonunionized nursing homes (P < 0.1) in Missouri, and had a higher median mortality percentage than nonunionized nursing homes (P < 0.05) in Alabama and Tennessee. Higher average resident age, lower percentage of Medicare residents, small size, for-profit ownership, and chain organization affiliation were associated with higher resident COVID-19 mortality percentage. Overall, no evidence was found that nursing home resident COVID-19 mortality percentage differed between unionized nursing homes and nonunionized nursing homes in the U.S., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Olson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The Hospital Price Transparency Final Rule, effective January 1, 2021, requires hospitals to post online a machine-readable file that includes payer-specific negotiated commercial prices for all services. The regulation aims to improve the affordability of hospital care by promoting price competition. However, a low compliance level among hospitals would compromise the operational effectiveness of this regulation. Understanding hospitals' compliance status to the regulation has important implications for its enforcement effort and effectiveness assessment., Objective: To analyze nationwide hospitals' compliance status to the Hospital Price Transparency Rule., Design: Cross-sectional observational study., Participants: A total of 3558 Medicare-certified general acute-care hospitals were examined., Main Measures: A binary compliance rating was generated by using data collected by Turquoise Health. "Noncompliance" means that no machine-readable file was posted or the posted file contains no commercial negotiated prices. "Compliance" means that a machine-readable file was posted with commercial negotiated prices for at least one insurance plan., Key Results: As of June 1, 2021, 55% of the 3558 Medicare-certified general acute-care hospitals we examined had not posted a machine-readable file containing commercial negotiated prices. Wide variations of compliance existed across states and hospital referral regions. A hospital's compliance status is strongly associated with the average compliance status of peer hospitals in the same market. Hospitals with greater IT preparedness, for-profit hospitals, system-affiliated hospitals, large hospitals, and non-urban hospitals had greater compliance. More concentrated hospital markets had greater average compliance., Conclusions: Hospitals take into consideration the behavior of their peers in the same market when making price disclosure decisions. Compliant hospitals are likely to have better IT preparedness, more financial resources and personnel expertise to mitigate the cost required for the implementation of the Price Transparency Rule. The compliance cost, therefore, might be a barrier for some hospitals., (© 2021. Society of General Internal Medicine.)

Hospitals acquire and maintain long-term operating assets such as land, buildings, and equipment. In this study, we analyzed hospitals' long-term assets acquisitions data extracted from the Medicare Cost Report, a mandatory annual filing for all Medicare-certified hospitals. The first objective of this study is to examine the time trend of land, buildings, and equipment acquisitions of all general acute care hospitals in the U.S. from 2005 to 2019 to understand the relative magnitude and temporal changes for the operating assets. The second objective is to examine the 15-year accumulated acquisitions of land, buildings, and equipment per capita in each state to understand the variations of potential access to hospital operating resources across states. To understand the longitudinal changes in acquisitions of operating assets for each year from 2005 to 2019, we calculated the total acquisition amounts across all hospitals for land, buildings, and equipment, respectively, and adjusted the amounts to 2019 dollars based on the consumer price index (CPI). For each state (including Washington D.C.) and the whole nation, the 15-year accumulated CPI-adjusted acquisition amounts per capita for land, buildings, and equipment were also calculated, respectively. The nationwide acquisitions of those operating assets grew rapidly from 2005 to 2008 followed by a negative overall growth from 2008 to 2014 and since 2015, started increasing steadily again. In 2019, U.S. general acute care hospitals acquired $3.0 billion of land, $44.6 billion of buildings, and $33.9 billion of equipment. Huge geographical variation in per capita cumulative total asset investment were also found with the first place North Dakota having a per capita investment that is almost four times higher than that in the lowest ranked state of Alabama., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Self-insured employers cover more people than Medicare, Medicaid, or direct purchasers of private insurance.This study examined the ability of self-insured employers to negotiate hospital prices and the relationship between hospital prices and employer market power in the United States., Study Design: Repeated cross-section analysis of commercial claims., Methods: We used the US Census Bureau County Business Patterns data to estimate employer market power at the metropolitan statistical area (MSA)-year level and used the Truven Health MarketScan commercial claims to estimate mean hospital prices and price ratios at the MSA-year level (2010-2016). We calculated descriptive statistics for employer market power, mean hospitalization prices, and a case mix-adjusted price ratio measure during the study period and analyzed the 10 most concentrated labor markets. We estimated MSA-year-level ordinary least squares regressions of hospitalization price and the price ratio measure on employer market power., Results: Large self-insured employers had concentrated market power in very few MSAs in 2016. The mean value of our employer market power measure was 62 for 2016, compared with the mean value of 5410 for hospital market power in the United States. Regression analyses find a slight relationship: A 1-point increase in employer market power was associated with a $6.61 decrease in the hospitalization price (mean = $20,813), but this result becomes statistically insignificant once the models control for hospital wages., Conclusions: Employer market power is low in most MSAs. Self-insured employers may consider building purchase alliances with state and local government employee groups to enhance their market power and lower negotiated prices for hospital services.

Charges for air ambulance services were 4.1-9.5 times higher than what Medicare paid for the same services in 2016. The median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent in 2012-16. Air ambulance charges varied substantially across the US, and some of the largest providers had among the highest charges.

California's Hospital Fair Pricing Act, passed in 2006, aims to protect uninsured patients from paying hospital gross charges: the full, undiscounted prices based on each hospital's chargemaster. In this study I examined how the law affects the net price actually paid by uninsured patients--a question critical for evaluating the law's impact. I found that from 2004 to 2012 the net price actually paid by uninsured patients shrank from 6 percent higher than Medicare prices to 68 percent lower than Medicare prices; the adjusted collection ratio, essentially the amount the hospital actually collected for every dollar in gross price charged, for uninsured patients dropped from 32 percent to 11 percent; and although hospitals have been increasingly less able to generate revenues from uninsured patients, they have raised the proportion of services provided to them in relation to total services provided to all patients. The substantial protection provided to uninsured patients by the California Hospital Fair Pricing Act has important implications for federal and state policy makers seeking to achieve a similar goal. States or Congress could legislate criteria determining the eligibility for discounted charges, mandate a lower price ceiling, and regulate for-profit hospitals in regard to uninsured patients., (Project HOPE—The People-to-People Health Foundation, Inc.)

Medical service charges, which remain consistent across all payers, do not affect the statutorily determined reimbursements from public payers, such as Medicare and Medicaid fee-for-service programs.[1], [2] These charges, however, have important implications for the price paid by private payers, uninsured patients, and out-of-network patients.[1], [2] Prior research found that service charges relative to Medicare payment varied across medical specialties in 2014 and the trend of charges relative to the Medicare payment differed among a few major medical specialties from 2012 to 2018.[1], [3] The specific trend for each individual medical specialty, however, remains unknown. 2010 USD were converted to 2019 USD using the Personal Consumption Expenditures Price Index SP b sp 2010 charge to Medicare payment ratio is not associated with % change in weighted average charge, 2010-2019 (correlation coefficient: 0.16; I P i = 0.25), or with % change in weighted average Medicare payment, 2010-2019 (correlation coefficient: 0.18; I P i = 0.20) Across all 51 specialties, the 2010-2019 percent change in weighted average charge is highly positively associated with the percent change in weighted average Medicare payment (correlation coefficient: 0.87; I P i < 0.001). [Extracted from the article]

The article presents the direct financial burden of COVID-19 testing on patients is largely removed by the Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act, and most insurers to eliminate cost sharing to hospitals for testing patients. Topics include the hospitals also are prohibited by the Department of Health and Human Services from balance billing patients, and the high hospital charges can lead to high payment by private insurance plans.

Importance: Although independent charity patient assistance programs improve patient access to costly prescription drugs, recent federal investigations have raised questions about their potential to increase pharmaceutical spending and to violate the federal Anti-Kickback Statute. Little is known about the design of the programs, patient eligibility, or drug coverage.Objective: To examine the eligibility criteria of the independent charity patient assistance programs and the drugs covered by them.Design, Setting, and Participants: Descriptive cross-sectional study of the 6 largest independent charities offering patient assistance programs for patients including, but not limited to, Medicare beneficiaries in 2018. These charities offered 274 different disease-specific patient assistance programs. Drugs were identified for subgroup analysis that had any use reported on the Medicare Part D spending dashboard and any off-patent brand-name drugs that incurred more than $10 000 in Medicare spending per beneficiary in 2016.Exposures: Support by independent charity patient assistance programs.Main Outcomes and Measures: The primary outcomes were the characteristics of patient assistance programs, including assistance type, insurance coverage (vs uninsured), and income eligibility. The secondary outcomes were the cost of the drugs covered by the patient assistance programs and the coverage of expensive off-patent brand-name drugs vs substitutable generic drugs.Results: Among the 6 independent charity foundations included in the analysis, their total revenue in 2017 ranged from $24 million to $532 million, and expenditures on patient assistance programs ranged from $24 million to $353 million, representing on average, 86% of their revenue. Of the 274 patient assistance programs offered by these organizations, 168 (61%) provided only co-payment assistance, and the most common therapeutic area covered was cancer or cancer treatment-related symptoms (113 patient assistance programs; 41%). A total of 267 programs (97%) required insurance coverage as an eligibility criterion (ie, excluded uninsured patients). The most common income eligibility limit was 500% of the federal poverty level. The median annual cost of the drugs per beneficiary covered by the programs was $1157 (interquartile range, $247-$5609) compared with $367 (interquartile range, $100-$1500) for the noncovered drugs. Off-patent brand-name drugs (cost: >$10 000) were covered by a mean of 3.1 (SD, 2.0) patient assistance programs, whereas their generic equivalents were covered by a mean of 1.2 (SD, 1.0) patient assistance programs.Conclusions and Relevance: In 2018, among 274 patient assistance programs operated by the 6 independent charity foundations, the majority did not provide coverage for uninsured patients. Medications that were covered by the patient assistance programs were generally more expensive than those that were not covered. [ABSTRACT FROM AUTHOR]

California’s Hospital Fair Pricing Act, passed in 2006, aims to protect uninsured patients from paying hospital gross charges: the full, undiscounted prices based on each hospital's chargemaster. In this study I examined how the law affects the net price actually paid by uninsured patients—a question critical for evaluating the law's impact. I found that from 2004 to 2012 the net price actually paid by uninsured patients shrank from 6 percent higher than Medicare prices to 68 percent lower than Medicare prices; the adjusted collection ratio, essentially the amount the hospital actually collected for every dollar in gross price charged, for uninsured patients dropped from 32 percent to 11 percent; and although hospitals have been increasingly less able to generate revenues from uninsured patients, they have raised the proportion of services provided to them in relation to total services provided to all patients. The substantial protection provided to uninsured patients by the California Hospital Fair Pricing Act has important implications for federal and state policy makers seeking to achieve a similar goal. States or Congress could legislate criteria determining the eligibility for discounted charges, mandate a lower price ceiling, and regulate for-profit hospitals in regard to uninsured patients. [ABSTRACT FROM AUTHOR]

Purpose Biosimilars can generate competition and provide cost savings over reference biologics for the Medicare program and beneficiaries. The extent to which these benefits can be realized in the Medicare Part D program depends on how biosimilars and biologics are placed in the formulary. We conducted a study to examine Medicare formulary placement of the first biologic to have 2 biosimilars on the market—infliximab and its biosimilars infliximab-dyyb and infliximab-abda. Methods All standalone and Medicare Advantage (MA) prescription drug plans (PDPs) offered in Medicare Part D were examined between September 2016 (ie, at the end of the last quarter before the launch of the first infliximab biosimilar) and September 2018, at which time a second biosimilar had been on the market for about 14 months. When PDPs covered both the reference biologic and a biosimilar, we compared the cost-sharing tier and the frequency of prior authorization and step therapy requirements for each drug. Results Nearly all PDPs covered infliximab throughout the study period. By September 2018, 31.7% of MA plans and 14.9% of standalone PDPs were covering a biosimilar on the market. Nearly all plans that covered a biosimilar also covered the reference product. Most plans (98% of standalone PDPs and 89% of MA plans) had placed prior authorization restrictions on both the biologic and the biosimilar. All plans covering both products placed them in the same cost-sharing tier. No plan required step therapy for either product. Conclusion Formulary placement of infliximab biologic and biosimilars in Medicare Part D is not optimized to generate cost savings for the Medicare program and beneficiaries, whose cost sharing is often based on the drug's list price. The Medicare program should provide incentives for PDPs to expand biosimilar coverage. [ABSTRACT FROM AUTHOR]