Cost considerations in the treatment of heart failure.
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Abstract:
Whether we are in academic medicine or private practice, a for-profit or a nonprofit institution, the treatment of heart failure is a business. In 2009, the estimated direct and indirect cost of treating heart-failure patients in the United States was more than $37 billion.1 Hospitals receive slightly more than $6,000 from Medicare for each admission, and the average stay lasts about 5.8 days.2 In this country, however, as many as 25% of heart-failure patients are readmitted within 30 days of discharge.3,4 For patients who are readmitted during this time span, Medicare does not reimburse the hospital, so the cost burden is shifted to the healthcare facility.
The following measures can help to ensure that left ventricular assist device (LVAD) therapy is affordable and accessible for future patients.
Communicating with Administrators Effectively. As heart-failure specialists, it is our duty to inform administrators about the importance of advanced therapies to a hospital's cost structure. We must show them that they will make an overall profit—maybe not per se from the patients who receive advanced therapies, but from the larger pool of patients who come to our centers because of the availability of these therapies.
Evaluating Our Heart-Failure Programs from a Business Standpoint. We need to evaluate our individual heart-failure programs from a business standpoint, so that we can speak the same language as our administrators. What strategies and assumptions underlie the everyday care of our patients? How do we incorporate advanced therapies into our program? What are our program's particular strengths and weaknesses? Can our program provide an adequate return on the hospital's investment in advanced therapies and the personnel required to implement them?
Fostering an Alliance between Institutions and Physicians. A crucial factor in incorporating these advanced therapies is an alliance between institutions and physicians. As a consequence of recent Medicare cuts, more and more cardiovascular care is being performed in integrated healthcare systems. For example, because diagnostic testing is reimbursed at a higher rate if performed in a hospital facility (rather than in a cardiologist's private office), some nonacademic hospital systems are now hiring physicians either directly or through a nonprofit organization that is supported by the hospital but governed by a separate board. This alignment of physicians and hospitals can promote the development of advanced cardiovascular programs that will provide a profit margin for the hospital and financial security for the physicians.
Some programs have a mixture of academic faculty members and private practitioners, rendering such alliances problematic in terms of their overall profitability. However, what we are marketing is not just advanced therapy but continuity of care for heart-failure patients. Hospital administrators need to be aware of the big picture: heart-failure clinics increase patient volume, generating substantial profit from diagnostic testing; this can offset the expense of one long hospitalization for a recipient of advanced therapies.
Selecting Patients Carefully. Patient selection is important, because well-chosen patients have a shorter length of stay, impose a lower cost burden, and may even generate a profit. Each medical review board is responsible for selecting patients likely to have the best outcomes. Those at too high a level of risk for advanced therapies may benefit from disease management and palliative care. Rather than use an expensive, fully implantable LVAD for high-risk patients in cardiogenic shock, it might be wiser to use a temporary device, which will allow time to reassess these patients and evaluate their neurologic and psychological status.
Enhancing Nutritional Care and Postoperative Discharge Planning. Malnutrition, a common finding in advanced heart-failure patients, is associated with an increased risk of infection and death in patients who receive mechanical circulatory support. To achieve optimal long-term outcomes in mechanical circulatory support patients, an interdisciplinary approach that incorporates a nutrition-support team is vital.
Long hospital stays can lead to a substantial deficit in even the most profitable mechanical circulatory support programs. Ideally, one nurse should focus on postimplantation discharge planning—examining each patient daily and asking what can be done that day to facilitate discharge. To help decrease the length of stay, some implant centers have developed partnerships with long-term acute-care facilities that have personnel specifically trained in LVAD therapy.
Using Reimbursement Specialists. Round-table sessions on the subject of reimbursement are another important resource. By doing a chart analysis, reimbursement specialists can identify major coding errors that prevent adequate reimbursement for supplies and clinical care. For instance, some programs make costly errors in billing for LVAD batteries: they bill for HeartMate® XVE batteries rather than HeartMate® II batteries, decreasing insurance reimbursement by $3,000 per patient; or they fail to bill for the LVAD pump, thereby absorbing the cost. Reimbursement resources are readily available, but most programs use them infrequently because of time constraints and lack of personnel to oversee coding and billing.Cite
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Under prospective payment utilizing the diagnostic related groups (DRG) classification, hospital administrators have begun to rethink accepted hospital procedures. It is now necessary to consider every factor that contributes to the cost of care, because those costs will be borne more and more by the hospital rather than the patient. Administrators must determine if an expenditure really improves the quality of care and shortens the length of stay. Unfortunately, in many cases there are no mechanisms or criteria for such an evaluation. The health care industry is in danger of cutting away tissue when the fat is being trimmed away. An effort tojustify and quantify the benefit of an infection control program in a 270-bed acute care general hospital led to eye-opening results, and a decision to expand the program rather than reduce it. The expanded program is expected to recover cost two-fold.
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Comprehensive coordinated care management for low-incident, high-cost diseases, like chronic renal failure, can provide a great opportunity for health plans to add immediate and significant profit to their bottom line. The resultant benefits of improved operations, improved clinical outcomes and increased patient satisfaction add further incentive for health plans to take action to implement outsourced disease management for this condition.
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Healthcare costs for the elderly are rising rapidly in the United States. One way for a hospital to control these rising costs is to implement a geriatric care management system. The goal of a such a system is to change the way the hospital treats medically complex Medicare patients and, thus, reduce unnecessary hospital costs. Such a system requires a process for identifying elderly patients in need of geriatric care management services, treating them efficiently, and assessing the system itself. An effective process usually results in significant cost savings for the hospital as well as improved patient care and satisfaction.
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This is the fourth in a series of seven articles.
Changing technology is probably the main force driving the substitution of healthcare resources. This is because new treatments, procedures, and diagnostic techniques allow conditions to be managed in different settings by different staff. Such change is generally incremental, but occasionally new technologies fundamentally change the organisation of care. For example, the development of effective chemotherapy in the 1940s allowed tuberculosis to be managed on an outpatient basis, which led directly to the closure of nearly 30 000 hospital beds and the elimination of an entire class of hospital. Advances in primary prevention might also, in the long term, lead to a reduced need for admission to hospital. Yet such step changes are ultimately outside the hands of clinicians, managers, and policymakers, despite their intimate concern with the organisation, scale, and cost of the hospital sector. The policy debate has tended to focus on what might be described as the “appropriateness gap”—how to provide substitute care for inpatients who do not strictly need to be in hospital because of current technologies.
#### Summary points
Changes in diagnostic and treatment technologies, rather than policy interventions, are the most potent force leading to the substitution of one form of healthcare service for another.
Many inpatient bed days and admissions are deemed inappropriate—but the appropriateness of admission to hospital can tell us nothing about whether patients would be more cost effectively cared for outside hospital.
Several services that attempt to be substitutes for hospital care—either by preventing admission or by hastening discharge—have been experimented with.
Many apparent substitutes for hospital care seem, in the United Kingdom, to increase overall demand for services, with little impact on overall hospitalisation or costs.
Most patients admitted to hospital in the United Kingdom have no alternative but to be admitted: they …
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Abstract In the U.S., medical oncology as a profession is wrestling with conflicting and often unrealistic clinical and financial expectations. Office-based practitioners face an environment of low reimbursement for cognitive care, high but declining reimbursement for chemotherapy and supportive care, and high income expectations of oncology professionals. As a field, there has been little incentive to assess or improve the quality of cancer care. Current incentives are often misaligned to reward doing the most aggressive and expensive actions, as long as patients are satisfied, because this leads to the highest return to the practice. Some consequences include U.S. cancer treatment costs that are twice that of any other nation with no or minimal differences in survival, late referrals (if at all) to hospice, and 14%–20% of patients receiving chemotherapy within 14 days of their death when it is highly likely to harm and cause complications. This pattern of care may lead to a significant risk for stress and burnout, as well as being economically unsustainable. Systematic change to reward value requires realignment of incentives to provide episode-based care free from incentives to give expensive chemotherapy or supportive care drugs without good evidence, and an external board to determine appropriate patterns of care. The only ways to reduce the cost of care are to reduce either the amount of care or the cost of care, and either has dramatic consequences in a field that has been built on high expectations. These actions will likely control costs, but in the short term will cause significant distress among patients, families, and health care practitioners.
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The federal government is currently offering bonus payments through Medicare and Medicaid to hospitals, physicians, and other eligible health professionals who meet new standards for "meaningful use" of health information technology. Whether these incentives will improve care, reduce errors, and improve patient safety as intended remains uncertain. We sought to partially fill this knowledge gap by evaluating the relationship between the use of electronic medication order entry and hospital mortality. Our results suggest that the initial meaningful-use threshold for hospitals-which requires using electronic orders for at least 30 percent of eligible patients-is probably too low to have a significant impact on deaths from heart failure and heart attack among hospitalized Medicare beneficiaries. However, the proposed threshold for the next stage of the program-using the orders for at least 60 percent of patients, a rate some stakeholders have said is too high-is more consistently associated with lower mortality. Our results suggest that the higher standard that will probably follow in the second stage of meaningful-use regulations would be more likely than the first-stage standard to produce the improved patient outcomes at the heart of the federal health information technology initiative.
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