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  • Understanding the Effects of COVID-19 on Hospital Volume and Finances

    The COVID-19 pandemic brought about a drastic downturn in hospital finances at a time when hospitals were called to play a frontline role in the fight against the pandemic.  According to projections from the American Hospital Association, hospitals will lose $323 billion in 2020 due to COVID-19, with $202 billion of this loss taking place in the first four months of the national health emergency in the US (March through June).  This financial downturn was driven by an unprecedented and abrupt reduction in the utilization of hospital services.  As the fight against the coronavirus continues, much remains uncertain.  Hospitals’ ability to navigate these uncertain times will depend, in part, on their success in anticipating and responding to future changes in the demand for hospital services.

    Below we present a conceptual framework for understanding changes in inpatient hospital services as a result of the pandemic.  Our framework suggests the following:

    • Hospitals’ pre-pandemic mix of inpatient services is a key determinant of the impact of COVID-19 on hospital finances.
    • Even though the total inpatient volumes may return to pre-pandemic levels, the mix of inpatient hospital services is likely to change due to COVID-19, forcing hospitals to rethink their financial calculus.

    A Conceptual Framework for Forecasting the Effect of COVID-19 on Inpatient Hospital Volume

    In examining the effect of COVID-19 on inpatient hospital utilization, it is important to consider how the pandemic affected the demand for inpatient hospital services. In forecasting utilization of hospital inpatient volume during COVID-19, we consider four components of hospital inpatient volume based on admission type.

    • Admissions from the emergency department (ED): Patient is admitted to the hospital through the ED, so these admissions tend to be unplanned and dependent on patients’ use of ED services. Reasons for these hospitalizations are varied and include trauma, heart attacks, and strokes.
    • Elective Admissions: Admissions are considered non-urgent and are planned ahead of time. Examples include joint replacement, spinal fusions, and procedures for obesity.
    • Non-Elective Admissions that are not from the ED: Hospitalizations that require urgent medical treatment but can be scheduled ahead of time, so the patient does not enter through the ED. Examples include cardiovascular procedures with stents and admissions for sepsis.
    • Pregnancy & Childbirth/Newborn: Hospitalizations for pregnancy, labor, delivery, and services for newborns.

    Note: Authors’ analysis of 2017 NIS data. N=4,584 hospitals

    Early evidence from select hospital systems shows that in April 2020 hospital admissions were down by up to 35% and surgeries down by up to 70% compared to April 2019.  More recently, hospitals are reporting their volumes have climbed back up since the early days of the pandemic, getting closer to pre-COVID levels.  A recent analysis of data from 201 hospitals in 36 states showed that all medical admissions declined by 34.1% in April and were still 8.3% below pre-COVID baseline by June/July.  These fluctuations in total hospital volume mask substantial variation in volume by admission type. Below, we summarize recent evidence on how COVID-19 affected each admission type.

    Hospitals’ pre-COVID mix of inpatient services is a key determinant of the impact of COVID-19 on hospital finances.

    Since pre-COVID shares of admissions within each category vary across hospitals, the effect of reduced demand for hospital services due to the pandemic will also affect hospitals differently.  Elective hospitalizations make up a relatively greater share of total hospitalizations in small hospitals (26.9%) as compared to larger hospitals (Medium: 14.4%; Large: 15.1%).  We observe similar patterns for rural and for-profit hospitals, when compared against urban and not-for-profit hospitals, respectively.  Hospitals that rely on a greater share of elective hospitalizations are more likely to be influenced by sharp fluctuations in elective surgeries that occurred earlier during the pandemic.  Small, rural, and not-for-profit hospitals also have a larger share of hospitalizations that are non-ED and non-elective relative to other hospitals within its hospital characteristic group.  As a result, these hospitals will have a larger impact from long-term shifts in outpatient care and telehealth services on their number of admissions.

    Note: Row percentages may not sum to 100% due to rounding.  Definition of small, medium, and large hospitals vary by region as indicated in NIS Description of Data Elements.

    Future Impact of COVID-19 on Hospital Admissions

    There is much uncertainty about how the pandemic will unfold and how hospitals will be impacted as a result in the coming months.  Although our medical sector in general and hospitals in particular may be better prepared to weather any new storms related to the pandemic, the incoming flu season is expected to bring new challenges.  Even if total hospital volume reaches pre-COVID levels, the distribution of hospitalizations across admission types is likely to change in the long run as a result of the pandemic.  The impact on hospital finances will be partially dependent on what the new distribution of hospitalizations across admission types looks like.

    Elective Admissions: If there is a jump in COVID-19 cases in the coming months, elective hospital admissions may fall sharply again, potentially due to state executive orders in areas that experience a surge in infections.  The long-term impact of COVID-19 on elective admissions will partially depend on patients’ demand for ambulatory care.  Furthermore, a recent report from the Commonwealth Fund shows that physician office visits and other ambulatory services have increased since the sharp declines in March and April but have leveled off 10 percent below their pre-COVID volume.  This suggests that as hospitals clear the backlog of previously canceled surgeries, the number of elective admissions may also plateau at a lower level than the pre-COVID volume if patients continue to avoid receiving outpatient care in the coming months.

    Non-Elective, Non-ED Admissions: The hospitalizations that fall in this category depend on ambulatory care, delivered in outpatient clinics and physician offices.  If patients stop going to doctors’ offices for routine or other care, they will be less likely to have hospitalizations that can be scheduled ahead of time and more likely to end up in the ED with potentially more severe conditions.  Delayed ambulatory care can reduce hospitalizations in this group and potentially even shift some of these hospitalizations to the admissions from ED.

    Admissions from the ED: There will be both upward and downward pressures on admissions from ED in coming months.  On one hand, the public’s anxiety over catching coronavirus in the hospital setting may keep ED visits and hospital admissions from ED low.  In fact, the magnitude of the decline in ED visits in Spring 2020 coupled with the observation that ED use and hospitalizations fell for acute conditions, such as heart attack and stroke, suggested that part of the reduction in admission from ED was due to people avoiding ED use for conditions that require prompt medical care.  On the other hand, heightened sensitivity about coronavirus may increase ED admissions as we head into a new flu season.  Furthermore, reduction in routine ambulatory care and elective surgeries may put upward pressure on ED visits as patients delay care until the last minute.  For example, many healthcare providers view the term “elective admissions” as misleading because hospitalizations in this category are needed, improve quality of life, and can become “non-elective” urgent hospitalizations if deferred for too long.  In the coming months, overall ED use and hospital admissions from the ED will be determined largely by the public’s attitudes towards avoiding prompt medical care and heightened sensitivity towards flu-like symptoms.

    COVID-19 has brought about sharp fluctuations in the volume of inpatient hospital admissions.  Forecasting future changes in the demand for hospital services and associated changes in hospital finances will be important as we continue the fight against the pandemic. A full accounting of the impact of COVID-19 on hospital finances will require consideration of changes in volume due to the pandemic as well as the payments associated with admission type.

    Key Take-Aways

    • Demand shocks due to the pandemic will vary across hospitals as hospitals differ in their share of admissions from the ED, elective admissions, and non-elective non-ED admissions.
    • Small, rural, urban non-teaching, and for-profit hospitals have a larger share of elective admissions and thus were more likely to be impacted by sharp fluctuations in elective surgeries that occurred earlier during the pandemic.
    • Elective hospitalizations make up a relatively greater share of total hospitalizations in small, rural, urban non-teaching, and for-profit hospitals.
    • Although the sharpest reductions in demand for hospital services in the short run were caused by executive orders on elective surgeries, in the long run, the changes in demand for hospital services will be driven by the upstream use of ambulatory care and patient preferences.
    • Even though hospitals may reach pre-COVID levels in total admissions, the impact on hospital finances will be dependent on how total admissions is distributed across admission types and service lines. To the extent that the distribution changes, hospitals will need to adjust to new financial pressures.
    Services : Blog, Payment Policy & Delivery System Innovation, Program Evaluation and Monitoring Expertise: ,

    The COVID-19 pandemic brought about a drastic downturn in hospital finances at a time when hospitals were called to play a frontline role in the fight against the pandemic.  According to projections from the American Hospital Association, hospitals will lose $323 billion in 2020 due to COVID-19, with $202 billion of this loss taking place

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  • Medicare Advantage and Post-Acute Care: Saving Money or Shifting Costs?

    In its April 2020 report, the Medicare Board of Trustees projects that the Hospital Insurance (HI) Trust Fund – basically, funding for Part A – will be depleted by 2026; Medicare will only be able to pay out 90 percent of benefits available under current law in that year.  With financial circumstances likely to worsen as a result of COVID-19, Congress will be looking for ways to extend the solvency of the Medicare program over the next few years.

    One approach favored by some would be to accelerate the growth of Medicare Advantage (MA), which would shift financial risk from the Federal Government to the private insurers that offer an MA plan.  In 2020, approximately 36 percent of Medicare beneficiaries are enrolled in an MA plan, which receives a fixed fee per enrollee, adjusted for clinical characteristics. Most beneficiaries are in Traditional Medicare (TM), but the Medicare Trustees project MA enrollment to continue to grow and reach 43.3 percent by 2030.

    Because MA plans receive fixed payments for their enrollees, they have an incentive to control healthcare use, including use of post-acute care (PAC), i.e., home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs).  PAC is perceived as a potential area for savings in Medicare, particularly after research has identified it as a key driver of geographic variation in TM. TM’s spending on PAC is significant, estimated at $58.5 billion in 2018.

    In a recent study, researchers at KNG Health Consulting compared PAC utilization in TM and MA as well as short-term acute care hospital (STACH) average length of stay by patient severity of illness (SOI) and select clinical conditions. The study found that for all levels of SOI and selected clinical conditions, the TM discharge rates to facility-based PAC (SNF, IRF, and LTCH) were higher than for MA beneficiaries, although differences in facility-based PAC rates between TM and MA narrowed some for the highest severity patients.  For patients with the highest SOI or the selected clinical conditions, MA beneficiaries had longer average length of stay at STACHs compared with TM beneficiaries.

    While the study findings are consistent with other recent studies that found MA enrollees were less likely to receive PAC services, it provides additional insights on variation in use of PAC among TM and MA beneficiaries.  First, the observed differences in PAC use for low severity beneficiaries suggests there may be opportunities for TM savings among these patients. Second, MA may substitute longer hospital stays for facility-based PAC and, specifically, for care in LTCHs, which care for the most severely ill Medicare beneficiaries.

    The study suggests that MA plans generate PAC savings by pushing costs onto short-term acute care hospitals for the most severely ill patients.  All good? Medicare saves money and MA plans compensate hospitals for the longer lengths of stay….or not.  Studies have documented that MA plans pay hospitals the same, on average, as TM or lower.  So, growth of MA shifts financial risk from TM onto hospitals, at least with respect to PAC use, to what effect? Lower hospital margins– yes, but a key unanswered question is the impact on beneficiary outcomes. With the relatively recent release of MA encounter data, researchers may be able to start answering this key question.

     

     

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  • Use of Glucarpidase (Voraxaze®) to Treat Methotrexate Toxicity in Cancer Patients Associated with Lower Length-of-Stay and Mortality Rates

    Glucarpidase (Voraxaze®) is used to treat methotrexate (MTX) toxicity in patients with delayed MTX clearance due to impaired renal function. Using 2010-2017 Medicare claims data, KNG Health researchers assessed outcomes of glucarpidase patients relative to those experienced by patients treated for presumed MTX toxicity using other therapies. Researchers examined hospital length of stay (LOS), mortality, and readmission rates for Medicare cancer patients with delayed clearance of MTX treated with glucarpidase.  They found that Medicare cancer patients with presumed MTX toxicity receiving conventional treatment experience long hospitalizations, high intensive care unit (ICU) use and high mortality. Glucarpidase patients had lower LOS, inpatient mortality and 90-day mortality than the non-glucarpidase patients.  The study was published in ClinicoEconomics and Outcomes Research.

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  • New Medicare Payment Policy Resulted in Poorer Outcomes for Patients Severe Wounds

    In Fiscal Year (FY) 2016, Medicare began phasing in a dual payment system for long-term care hospitals (LTCHs) that would pay an LTCH differently for cases meeting criteria (“qualified” cases) and cases that did not meet criteria (“site-neutral” cases).  Under a fully implemented system, for LTCHs to meet criteria for a qualified case, a patient must have been discharged from a STACH immediately prior to the LTCH stay, and have spent at least 3 days in an intensive care unit during the STACH stay or received at least 96 hours of mechanical ventilation in the LTCH. For site-neutral cases, an LTCH will be paid the short-term acute care hospital (STACH) amount or its costs, whichever amount is lesser.

    LTCHs, which treat chronically critically ill and medically complex patients who require hospital-level care for extended periods, are a particularly important care setting for severe wound patients. Medicare Fee-for-Service patients hospitalized with severe wounds in 2015 were six times more likely to be discharged to an LTCH compared to all Medicare discharges (7.1% vs 1.2%).  In FY 2015, 54% of severe wound patients treated in LTCHs would not have met criteria, and LTCHs treating these patients would have been at risk of receiving payment reductions between 20–40% for these cases during the phase-in period.

    KNG Health researchers developed a difference-in-difference model to examine the effects of the recent changes in the LTCH Medicare payment policy on treatment patterns and outcomes for site-neutral severe wound patients.  The findings, published in the Journal of Medical Economics, show that the new patient criteria for LTCHs were associated with fewer site-neutral severe wound cases going to LTCHs, and higher readmissions and post-discharge sepsis.

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  • The Effects of Calcitonin Gene-Related Peptide Inhibitors on Migraine Days, Healthcare Use, and Workplace Productivity: A Markov Model Approach

    Migraine is a debilitating condition in which painful headaches occur frequently.  Treatments for migraines, such as acute care treatment and preventive therapy, can help migraine sufferers manage their pain and reduce their frequency. However, there have been few recent improvements in the market for preventive migraine therapies.  Calcitonin gene-related peptide (CGRP) inhibitors are a new class of preventive migraine drugs that may address the need for new, effective treatments for migraines.

    In this study, we estimate the value of CGRP inhibitor treatment for chronic and episodic migraine sufferers. We used a Markov model framework with four primary outcomes: (1) migraine days; (2) acute care drug treatment days; (3) number of physician and emergency room visits; and (4) workplace productivity.  We considered the impact of CGRP inhibitors on patients who are not currently on preventive therapy because existing non-CGRP inhibitor treatments are ineffective or intolerable for these patients.

    Use of CGRP inhibitors was on average associated with fewer migraine days per year (-18.68/-29.20 for EM/CM), fewer triptan uses per year (-3.21/-5.04), more physician visits for migraine per year (1.03/1.02), fewer ER visits per year (-0.06/-0.10), higher probability of full-time (0.03/0.02) and part-time employment (0.01/0.00), fewer lost productive hours per year (-39.69/-21.31), and less indirect cost per year (-$20,327/-$11,176). Effects were generally greater for individuals with higher response to the drugs and varied by age and sex.

    If all migraine sufferers not on preventive medicine used CGRP inhibitors, we estimate national indirect cost savings of $390 billion for EM and $6 billion for CM over 10 years, as well as national reductions in migraine days per year of 358 million for EM and 16 million for CM.

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  • Quality Measure Development and Assessment for Ambulatory Surgery Centers

    KNG Health provides statistical support to The Ambulatory Surgery Center Quality Collaboration (ASC QC) to evaluate quality measures proposed for inclusion in CMS’ ASC Quality Reporting Program.  KNG Health has conducted statistical evaluation of select measures in terms of reliability, validity, feasibility, and interpretability based on data collected through pilot testing.  As part of its quality measure work for ASC QC, KNG Health has also developed a data collection tool for measure reliability testing, which included automation and consistency checks to minimize data entry error.  In addition, KNG Health has analyzed data from Culture of Patient Safety Survey data from ambulatory surgery centers and developed both facility-level and organizational-level reports that use data visualization tools to illustrate analysis results.

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