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Aim To report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021. Setting GI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School. Methods This was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020. Results Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing “live” to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing “live” GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner’s income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual. Conclusion Reports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection.

ImportanceThe COVID-19 pandemic challenged the financial solvency of hospitals, yet there is limited evidence examining hospital financial performance through the first 15 months of the pandemic.ObjectiveTo assess the financial outcomes associated with the COVID-19 pandemic in California hospitals.Design, Setting, and ParticipantsThis cross-sectional study tracked the financial performance of 348 hospitals in California using Hospital Quarterly Financial and Utilization Data from the State of California Office of Statewide Health Planning and Development. Hospital financial performance was examined from January 2019 to June 2021 for all hospitals in aggregate and by safety-net status.ExposuresPre–COVID-19 financial outcomes vs COVID-19 period outcomes.Main Outcomes and MeasuresQuarterly revenues, expenses, and profits.ResultsIn 348 California hospitals, hospital financial performance was highly variable during the COVID-19 pandemic. Losses were reduced by COVID-19 relief funding and strong equities market performance starting in the second quarter of 2020. Non–safety net hospitals maintained positive operating margins throughout the pandemic, while safety-net hospitals experienced large losses. Between the first quarter of 2020 and the second quarter of 2021, California safety-net hospitals’ net operating losses were more than $3.2 billion.Conclusions and RelevanceIn this cross-sectional study of California hospitals, hospital financial performance was tracked between the first quarter of 2019 and the second quarter of 2021. Although hospitals experienced reduced profits between January 2020 and June 2021, the interventions of government assistance programs were able to mitigate more detrimental fiscal consequences. When compared with non–safety net hospitals, safety-net hospitals were confronted with more concentrated financial losses.

Health care-based negative production externalities, such as greenhouse gas emissions, underscore the need for hospitals to implement sustainable practices. Eco-certification has been adopted by a number of providers in an attempt, for instance, to curb energy consumption. While these strategies have been evaluated with respect to cost savings, their implications pertaining to hospitals’ financial viability remain unknown. We specify a fixed-effects model to estimate the correlation between Energy Star certification and 3 different hospitals’ financial performance measures (net patient revenue, operating expenses, and operating margin) in the United States between 2000 and 2016. The Energy Star participation indicators’ parameters imply that this type of eco-certification is associated with lower net patient revenue and lower operating expenses. However, the estimated negative relationship between eco-certification and operating margin suggests that the savings in operating expenses are not enough for a hospital to achieve higher margins. These findings may indicate that undertaking sustainable practices is partially related to intangible benefits such as community reputation and highlight the importance of government policies to financially support hospitals’ investments in green practices.

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

BACKGROUND: The Hospital Value‐Based Purchasing Program (HVBP) is a pay for performance system that impacts traditional Medicare fee‐for‐service payments to hospitals through rewards and penalties. OBJECTIVES: To explore variation in overall and individual‐hospital total performance score (TPS) and embedded domains for hospitals during 2014‐2018. DATA SOURCE: Hospital data were retrieved from the publicly available HOSArchive dataset. STUDY DESIGN: Distribution of annual TPS and HVBP domain scores for 2014‐2018 was evaluated using descriptive statistics. Transitional probabilities were analyzed to evaluate annual movement in the TPS ranking for outlier hospitals in the Top and Bottom 5%. PRINCIPAL FINDINGS: TPS scores are positively skewed while the distribution of domain scores vary with patient experience, (clinical) outcome, and efficiency domains having a large number of (positive) outliers. Mean TPS score decreased from 40.54 in 2014 to 38.04 by 2018. Improvement was shown in mean domain scores for clinical process of care and clinical outcome using 95% confidence intervals, with hospitals gaining 10 points over the study period in clinical outcome. Changes in the mean scores for other domains did not show consistent increases or decreases. Chi‐square analyses of hospital ranking categories showed some evidence that, as a group, hospitals initially ranked in the Bottom 5% are making consistent annual movements to higher categories. In contrast, over half of the hospitals ranking in the initial Top 5% remained in the top category across all study years. CONCLUSIONS: It may be time for CMS to redesign the HVBP incentive program to assure the measures accurately demonstrate sustained improvement, the domain weights appropriately reflect the level of importance, and the TPS comparative ranking methodology does not discourage lower‐performing hospitals from actively improving the care they deliver and achieving top ranks.

Background Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. Methods A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. Results Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. Conclusions Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.

Background It is important that policy makers, emergency physicians, hospital administrators, and health system planners understand the expanded role of hospital emergency departments (EDs). Objectives We sought to document the expanded role hospital EDs and their economic impact on overall hospital activity between 2002 and 2017. Methods This is a retrospective analysis of hospital ED capacity, utilization, and financial data from all general acute care hospitals in California (2002 through 2017). We calculate changes in ED capacity, annual ED visits and admissions through the ED, and the share of total hospital charges associated with ED generated utilization. Results EDs now account for well over half of all inpatient admissions to the hospital and ED outpatient visit volume has also grown substantially over time. By 2017 EDs within California's general acute care hospitals generated 67% of the total hospital economic activity (as measured by charges), up from 40% in 2002. Conclusion Overall, our data reveal that EDs are now the economic engine of hospitals and play a much larger role in the overall health care system, suggesting many unexplored policy, manpower, market, and health system design implications for further research.

BackgroundTo increase bed capacity and resources, hospitals have postponed elective surgeries, although the financial impact of this decision is unknown. We sought to report elective surgical case distribution, associated gross hospital earnings and regional hospital and intensive care unit (ICU) bed capacity as elective surgical cases are cancelled and then resumed under simulated trends of COVID-19 incidence.MethodsA retrospective, cohort analysis was performed using insurance claims from 161 million enrollees from the MarketScan database from January 1, 2008 to December 31, 2017. COVID-19 cases were calculated using a generalized Richards model. Centers for Disease Control (CDC) reports on the number of hospitalized and intensive care patients by age were used to estimate the number of cases seen in the ICU, the reduction in elective surgeries and the financial impact of this from historic claims data, using a denominator of all inpatient revenue and outpatient surgeries.ResultsAssuming 5% infection prevalence, cancelling all elective procedures decreases ICU overcapacity from 340% to 270%, but these elective surgical cases contribute 78% (IQR 74, 80) (1.1 trillion (T) US dollars) to inpatient hospital plus outpatient surgical gross earnings per year. Musculoskeletal, circulatory and digestive category elective surgical cases compose 33% ($447B) of total revenue.ConclusionsProcedures involving the musculoskeletal, cardiovascular and digestive system account for the largest loss of hospital gross earnings when elective surgery is postponed. As hospital bed capacity increases following the COVID-19 pandemic, restoring volume of these elective cases will help maintain revenue.DECLARATIONSEthics approval and consent to participateThis study did not meet criteria for IRB review.Consent for publicationNot applicableAvailability of data and materialsTo facilitate research reproducibility, replicability, accuracy and transparency, the associated analytic code is available on the Open Science Foundation [1] (OSF) repository, [DOI 10.17605/OSF.IO/U53M4] at [https://osf.io/u53m4]. The data that support the findings of this study were obtained under license from Truven. Data were received de-identified in accordance with Section 164.514 of the Health Insurance Portability and Accountability Act (HIPAA).Competing interestsJET received modest financial support for speakers fees from LivaNova and from Philips Healthcare, outside of the work. The other authors declare that they have no competing interests.FundingJET is supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript.Authors’ contributionsJET, JH had full access to all the data in the study, takes responsibility for the integrity of the data, the accuracy of the data analysis, and the integrity of the submission as a whole, from inception to published article. JET, HH, BSB, JC, MM, JJH, JH conceived study design; JET, HH, BSB, JC, MM, JJH, RD, BK, AJC, JH contributed to data acquisition and analysis; JET, HH, JJH, JH drafted the work; all authors revised the article for important intellectual content, had final approval of the work to be published, and agree to be accountable to for all aspects of the work.AcknowledgementsNot applicable

Informed decisions concerning emerging technologies against dengue require knowledge about the disease’s economic cost and each stakeholder’s potential benefits from better control. To generate such data for Indonesia, we reviewed recent literature, analyzed expenditure and utilization data from two hospitals and two primary care facilities in Yogyakarta city, and interviewed 67 dengue patients from hospital, ambulatory, and not medically attended settings. We derived the cost of a dengue episode by outcome, setting, and the breakdown by payer. We then calculated aggregate Yogyakarta and national costs and 95% uncertainty intervals (95% UIs). Dengue costs per nonfatal case in hospital, ambulatory, not medically attended, and overall average settings were US$316.24 (95% UI: $242.30–$390.18), US$22.45 (95% UI: $14.12–$30.77), US$7.48 (95% UI: $2.36–$12.60), and US$50.41 (95% UI: $35.75–$65.07), respectively. Costs of nonfatal episodes were borne by the patient’s household (37%), social contributors (relatives and friends, 20%), national health insurance (25%), and other sources (government, charity, and private insurance, 18%). After including fatal cases, the average cost per episode became $90.41 (95% UI: $72.79–$112.35). Indonesia had an estimated 7.535 (95% UI: 1.319–16.513) million dengue episodes in 2017, giving national aggregate costs of $681.26 (95% UI: $232.28–$2,371.56) million. Unlike most previous research that examined only the formal medical sector, this study included the estimated 63% of national dengue episodes that were not medically attended. Also, this study used actual costs, rather than charges, which generally understate dengue’s economic burden in public facilities. Overall, this study found that Indonesia’s aggregate cost of dengue was 73% higher than previously estimated, strengthening the need for effective control.

Background Isavuconazole (ISA) is a frequently used antifungal agent for the treatment of invasive fungal diseases (IFDs). However, hospital reimbursement data for ISA is limited. Objectives The primary objective of this study was to analyse the different perspectives of relevant stakeholders and the (dis)incentives for the administration of ISA in Germany. To that aim, the health economic effects of using ISA from a hospital management perspective were analysed. Patients/methods Based on principal-agent theory (PAT), the perspectives of (a) the patient (principal) as well as (b) physicians, (c) pharmacists and iv. hospital managers (all agents) were analysed. For the evaluation of the cost-containment and reimbursement strategies of ISA, the German diagnosis-related group (G-DRG) system was used. Results Hospitals individually negotiating additional payments for innovative treatment procedures (zusatzentgelte [ZE]) within the G-DRG system is a key element of hospital management for the reduction of total healthcare expenditure. Our analysis demonstrated the beneficial role of ISA in healthcare resource utilisation, primarily due to a shortened overall length of hospital stay. Depending on underlying disease, coded G-DRG and ISA formulation, large differences in total reimbursement and the amount of ZE was shown. The PAT demonstrated disincentives for hospital managers to use innovative drugs. Conclusions Based on the PAT, beneficial, detrimental and indifferent perspectives of different stakeholders regarding the usage of ISA were shown. A reduction of bureaucratic hurdles is needed in Germany for the extension of effective and innovative antifungal treatment strategies with ISA.

Background Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity. Objective To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance. Design We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments. Subjects US hospitals. Measures Medicare payments. Results There were 120 hospital-condition pairs in wave 1, 264 in wave 2, and 300 in wave 3. Wave 1 hospitals had similar savings to controls early in the program (0-6 mo difference in differences -$10, P=0.976; 6-12 mo +$295, P=0.441; 12-18 mo -$540, P=0.218; 18-24 mo -$485, P=0.259) but had greater savings than controls at 24-30 months (difference in differences -$663, P=0.035). Wave 2 (0-6 mo +$193, P=0.524; 6-12 mo -$183, P=0.489; 12-18 mo -$162, P=0.618) and wave 3 hospitals (0-6 mo +$79, P=0.753; 6-12 mo -$32, P=0.876) did not achieve significant savings at any time interval. There were no differential changes in patient outcomes over time. Conclusions Hospitals that joined BPCI earliest began to achieve savings at roughly 2 years of participation. These findings have implications for this and other alternative payment models.

South Korea's large hospitals are severely burdened by patient congestion because patients throng to these places expecting to get treated better given their higher-quality healthcare. Effective cost management of the healthcare system is one way to reduce patient congestion in a large hospital. This study proposes methods that can help direct patient flows in a desirable direction and suggests ways to effectively manage the cost of healthcare. The study also discusses how selfish patients act in ways that maximize their benefits by choosing a specific hospital and in turn forcing the hospital and the healthcare network to bear more costs than is necessary. The study proposes a model describing the need for intervention from the government to control the cost escalation resulting from selfish routing. The study proposes two heuristic algorithms to solve the suggested model. The flow-based algorithm addresses the target quantum of flows, and the utility-based algorithm targets the value of cost functions. Performances of heuristics are evaluated through numerical experiments. The utility-based algorithm yields higher values for objectives, while the flow-based algorithm controls the extent of investment. A case study based on data from the Seoul city database is also analyzed. The cost adjustment policy is compared with simple, uniformly improved network policies, and findings show that such policies have the strength needed to improve the cost-effectiveness of the healthcare system if implemented fully and effectively.

Investment and funding has continued to flow into biotech, unlike most business sectors. But with healthcare and hospital budgets increasingly under pressure, do belt-tightening and consolidation lie ahead? Melanie Senior investigates, with additional reporting by Riku Lahteenmaki.

PurposeThe purpose of this paper is to examine whether patient readmission rates are associated with patient satisfaction and Medicare reimbursement rates in the US hospitals.Design/methodology/approachThe Hospital Compare database was obtained from the Centers for Medicare and Medicaid Services (CMS) in the US. A total of 2,711 acute care hospitals were analyzed for this present study. The data included patient satisfaction surveys, hospital 30-days readmission ratios for heart failure and pneumonia patients and related payments. Exploratory factor analysis was applied in the first stage to operationalize constructs for scale development. Partial least squares (PLS) modeling analysis via Smart-PLS was utilized for testing the hypotheses.FindingsResults indicated that data provided from the Hospital Compare database for the acute care hospitals accurately reflect quality outcomes. Nevertheless, the Medicare Hospital Readmissions Reduction Program (HRRP) did not penalize the hospitals when patients reported lower satisfaction via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.Originality/valueThe findings suggest that a high-readmission rate is not associated with lower payment. Such results appear to conflict with the goals of value-based purchasing programs, which seek to penalize hospitals financially for higher readmission rates.

Study objective In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This global budget revenue program gives hospitals strong incentives to tightly control patient volume and meet budget targets. We examine the effects of the global budget revenue model on rates of admission to the hospital from emergency departments (EDs). Methods We used medical record and billing data to examine adult ED encounters from January 1, 2012, to December 31, 2015, in 25 hospital-based EDs, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total Patient Revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. We conducted difference-in-differences analyses for overall ED admission rates, ED admission rates for ambulatory-care-sensitive conditions and non–ambulatory-care-sensitive conditions, and for clinical conditions that commonly lead to admission. Results In 3,175,210 ED encounters, the ED admission rate for Maryland global budget revenue hospitals decreased by 0.6% (95% confidence interval –0.8% to –0.4%) compared with that for non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and decreased by 1.9% (95% confidence interval –2.2% to –1.7%) compared with that for Total Patient Revenue hospitals, a 9.5% relative decline. Relative declines in ED admission rates were similar for ambulatory-care-sensitive-condition and non–ambulatory-care-sensitive-condition encounters. Admission rate declines varied across clinical conditions. Conclusion Implementation of the global budget revenue model led to statistically significant although modest declines in ED admission rates within its first 2 years, with declines in ED admissions most pronounced among certain clinical conditions.

To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%,0.0001), and overall paired cost difference = $915 (P0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P0.0001), and paired cost difference = $3773 (P0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

SUMMARY Ambulatory care is a key to achieving better population health-not traditional ambulatory (outpatient) care, but rather ambulatory care reimagined. Ambulatory care is so vital that we at Intermountain Healthcare redesigned our entire organization to prioritize it and give it the attention it deserves.Historically, outpatient care was a point of access that connected many patients with specialty care, where hospitals made their money. Doctors in private practices referred their patients to the hospitals with which they were affiliated, and that arrangement provided the hospitals with a stream of patients on which they relied financially. Today, ambulatory care plays an entirely different role in the context of population health. Healthcare providers are paid a flat fee per person and gain a benefit when people stay healthy. In this new context, ambulatory care is a mechanism to get ahead of health problems and avoid more extensive treatments.This change then begs a question: How do healthcare providers support their essential services if ambulatory care is working to reduce the stream of patients to hospitals? The answer has three parts, and it is the reason we redesigned Intermountain Healthcare and began to roll out a series of new products and initiatives to implement that redesign.

This cross-sectional study examines the number and characteristics of hospitals that performed well or poorly across 3 Medicare value-based programs in fiscal year 2020.

In order to study the clustering algorithm based on density grid, the performance evaluation index system of hospital economic management under the application of electronic health management system is constructed. Firstly, this work designs the basic architecture of electronic health management system, classifies and screens the process of index system of electronic health management system, compares the clustering algorithm based on density grid with the simple clustering algorithm based on density or grid, and then applies it to the performance evaluation index system of hospital economic management. According to the principle of Mitchell scoring method, the expert questionnaire of hospital economic management performance evaluation index system was designed, and Delphi method was used to evaluate the candidate indexes from the three dimensions of right, legitimacy, and urgency. The results show that, compared with simple network clustering algorithm and density clustering algorithm, the clustering algorithm based on density network produces higher purity (94% VS 73% VS 67%) and lower entropy (0.9 VS 1.4 VS 1.54), which effectively saves memory consumption, and the difference is statistically significant (P

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare’s Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals’ 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.

Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.

A minor operations clinic has been providing a "one-stop shop" at our regional New Zealand hospital for the past decade to service management of skin lesions. This study aims to assess demographics, service characteristics, clinical standards and cost-savings from this setup, and to identify areas for improvement and potentially provide a model for other health units.All patients seen between May 2009 and June 2019 were prospectively included. Data includes demographics, waitlist period, referral sources, follow-up destinations, histology including involvement of margins and cost.A total of 4,926 patients were included, with 6,442 procedures overall. Median age was 72 years old. The main source of referrals was primary care. The majority of patients were returned directly to primary care. Median wait-time was 66 days, and this remained static over the decade. 56.6% of excised lesions yielded malignant histology and 90.1% achieved clear margins. There was a calculated saving of NZ$607.00 per patient with our one-stop shop compared to our previous traditional model. A further calculated saving of NZ$452,028.50 was achieved by diverting complex procedures from requiring operating theatre environments.Our model provides successful, streamlined and cost-effective treatment of skin lesions for our community. This model (or aspects of) may be similarly effective in other regional centres.

Several European countries have followed the USA in introducing prospective payment for hospitals with the expectation of achieving cost efficiency gains. This article examines whether theoretical expectations of cost efficiency gains can be empirically confirmed. In contrast to previous studies, the analysis of hospitals in Switzerland provides a comparison of a retrospective per diem payment system with a prospective global budget and a payment per patient case system. Using a sample of approximately 90 public financed Swiss hospitals during the years 2004–2009 and Bayesian inference of a standard and a random parameter frontier model, cost efficiency gains are found, particularly with payment per patient case. Prospective payment, designed to put hospitals at operating risk, is more effective in terms of cost reduction than the retrospective alternative. However, hospitals are heterogeneous with respect to their production technologies, making a random parameter frontier model the superior specification for Switzerland.