University of Miami Hospital overbilled Medicare $3.7 million, audit says

BY DANIEL CHANG
dchang@MiamiHerald.com

CARL JUSTE / MIAMI HERALD FILE

University of Miami Hospital.

The University of Miami Hospital will have to refund $3.7 million to Medicare after a federal audit of the hospital’s billing practices found the hospital overbilled in 2009 and 2010, according to a report released Tuesday by the U.S. Department of Health and Human Services Office of Inspector General.UM issued a statement Tuesday saying the university is working “with the relevant federal agencies to determine the correct amount owed for billing inaccuracies.”
In July, UMH Chief Financial Officer Darryl Caulton filed a letter contesting the inspector general’s method for calculating the refund to Medicare, saying the hospital “disagrees” with the way the figure was determined.
The federal audit covered $22.8 million in Medicare payments to the hospital for 2,194 claims that HHS officials considered “at risk’’ for billing errors. From that pool of claims, investigators randomly selected for review a sample of 200 inpatient claims for services between April 2009 and December 2010 that totaled $2.9 million in payments.
Investigators found that although the hospital complied with Medicare billing requirements for the majority of the 200 claims reviewed, 68 claims — representing $524,009 in overpayments — did not comply with agency rules.
Based on those findings, investigators extrapolated the total amount of overpayments to be approximately $3.7 million.
“Overpayments occurred primarily because the hospital did not have adequate controls to prevent incorrect billing of Medicare claims within the selected risk areas that contained errors,’’ according to the inspector general’s report.
Investigators identified the questionable claims using computer matching, data mining and analysis of inpatient claims.
According to the report, the hospital overbilled Medicare in five ways:
First, hospital administrators incorrectly billed Medicare for patient stays that should have been billed either as outpatient or outpatient with observation services.
“These errors occurred because of weaknesses in the hospital’s review process and turnover in case management leadership,” according to the report. Investigators estimated the errors caused Medicare to overpay about $448,000.
In addition, investigators found that in three cases the hospital billed Medicare separately for a patient’s discharge and readmission on the same day — even though those charges are supposed to be combined into a single claim. The three cases, between April 2009 and December 2010, caused overpayment of about $33,645, the report found.
The third type of overbilling came through use of incorrect diagnostic codes, the report said, which occurred in five of the 200 cases reviewed, and led to overpayments of $17,475.
UM hospital administrators also erred by billing Medicare for three patient discharges that should have been coded as transfers because the patients were readmitted to other hospitals the same day they were released from UM Hospital. That led to another $16,407 in overpayments, according to the report.
Lastly, HHS investigators said UM overbilled Medicare by about $8,500 for one claim because the hospital didn’t get an available credit for a replaced medical device.
According to the report, the hospital may be able to re-bill Medicare for some of the claims that were found to be overpaid.
In a six-page letter addressed to HHS auditors, Caulton, the hospital’s CFO, said the institution accepts the findings and will tighten internal controls by using an electronic quality review process. Caulton also said the hospital will improve billing controls, conduct quarterly audits of short stay accounts and place an automatic hold on Medicare claims for patients staying less than three days until the claims are released by a case manager.
But Caulton took issue with the methodology used to calculate the refund amount, and requested that HHS reconsider the sum.
He said that some of the questionable claims may be eligible for re-billing and that federal officials should not have used a sample of cases to estimate the refund amount without first resolving the re-billing question.
In the letter, Caulton noted that other audits by the inspector general “almost without exception” recommended repayment solely of the audited cases — not estimates based on a sample of claims.
“There is no reasoned basis for treating UMH differently,’’ Caulton wrote.
Donald White, a spokesman for the HHS inspector general, said extrapolation is an “extremely common” practice in determining Medicare overpayments. But he added that the refund amount is a recommendation.
The next step, White said, is for UM administrators to negotiate a repayment amount with the Center for Medicare and Medicaid Services, which administers the programs. The process usually takes 60 to 90 days, he said, but “given the government shutdown, it could be longer.”
The university bought the 560-bed former Cedars Medical Center in 2007 for $275 million. The purchase was one of several high-profile steps in the expansion of the Miller School of Medicine that included hiring more than 100 renowned researchers and creating a biotech research park to boost the school’s national profile.
The ambitious moves elevated UM’s medical school to the national stage, but they also may have seriously hampered it. In spring 2012, after suffering a $24 million loss for the first six months of that fiscal year, the medical school laid off more than 900 full- and part-time employees.
In August, UM and Jackson ratified their annual operating agreement for $102.5 million, the lowest-budgeted agreement in seven years. In the agreement, a binding letter of intent commits both institutions to multi-year exclusivity provisions for transplant, trauma, pediatrics and obstetrics services.

http://www.miamiherald.com/2013/10/08/3678166/university-of-miami-hospital-overbilled.html

Read more here: http://www.miamiherald.com/2013/10/08/v-print/3678166/university-of-miami-hospital-overbilled.html#storylink=cpy

Harvard Pilgrim Brings Medicare Advantage to Central Mass.

MICHAEL NOVINSON

Following a three-year hiatus, Harvard Pilgrim will once again offer Medicare Advantage in Worcester County.

The Wellesley-based health plan will reintroduce its Medicare plan to Worcester and three other Massachusetts counties at the start of 2014, the company announced Tuesday.

"It's best for the seniors," said Deb Rittenour, vice president for senior programs. "We're giving them options and we're giving them choice."

Senior citizens can begin signing up for Harvard's Medicare Advantage plan Oct. 15. The company is looking to expand its Medicare coverage to additional Bay State counties in 2015, Rittenour said.

Harvard Pilgrim discounted its fee-for-service Medicare offerings for Worcester County and elsewhere in 2010 after the federal government made the incentives for such plans less favorable, Rittenour said. Medicare Advantage is offered by commercial insurance companies, who in turn, are compensated by the federal government.

http://www.wbjournal.com/article/20131008/NEWS01/131009955/1002

Embedding shared decision making in primary care

Sharing decision making with the patient benefits individuals and the NHS as a whole

Making shared decision making a reality can be acheived if it is streamlined into routine NHS processes. Photograph: 3M

Overview

"No decision about me, without me" is the fundamental principle underpinning many of the current changes in NHS healthcare. Healthcare professionals may fail to recognise how knowledgeable patients are, or to understand the beliefs of individuals and groups. By engaging in balanced discourse, clinicians not only help a person come to terms with their needs and the potential gains and losses from different treatment approaches, but also broaden their own understanding of what is important to people.

The principle of engaged patients being well informed and taking a central role in all decisions made in their care is neither new nor revolutionary, but some patients may be passive receivers of care and many medical professionals, inadvertently or otherwise, are paternalistic in their delivery. Sharing decision making with the patient, referenced to understandable evidence and timely support when selecting investigation and treatment options, benefits not only individuals but the system as a whole.

Project Aims and Methods

Making shared decision making (SDM) a reality for patients can only be achieved if it is systematically streamlined into routine NHS processes, steering clear of lengthy bureaucracy. Nationally, a number of tools have been produced which now need to be rolled out locally and regionally. In order to support this work in the south of England, a 'community of interest' has been established to enable interested clinicians, who want to know more, to access training, ideas and peer support to try things out in their own clinical context.

Activities in the community of interest include a focus on integrating shared decision making so it becomes an integral part of the patient pathway and clinical behaviours. As well as embedding shared decision making from the provider perspective, SDM needs integrating into policies, commissioning systems and consent procedures. A particular focus therefore for the community of interest is to provide information, insight and advice about how clinical commissioning groups (CCGs) can deliver on their statutory duties, including practical tools and processes, and indicators of what "good commissioning of shared decision making would look like" at CCG level. A range of different activities have been delivered since the community was established, utilising new technologies to spread the word through different channels.

Findings

Twenty-two clinical commissioning groups across the south of England responded to an initial survey. Ninety-five per cent of respondents asked for more information or support on shared decision making. Fifty-six per cent of respondents definitely understood what SDM is trying to achieve and 63% indicated that SDM featured in their CCG plan. In relation to CCG plans, 45% included SDM in planned care (specifically MSK) and 35% in relation to long-term conditions. Fieldwork indicates that, in reality, CCGs are at very varied stages in their development which can be categorised as:

• Interested in SDM and currently developing an understanding of how to implement in practice
• Interested and with some engagement to introducing SDM in an identified clinical area
• Have a full SDM plan with internal accountability for delivery

The implications for the community of interest are to develop a wider suite of options to address the variability in practice. Regular WebEx updates from practitioners, tailored visits and expert mentorship to support specific initiatives, and the development of materials for patients and clinicians, are all part of the range of offerings needed to move individual CCGs on from their various starting points.

Recommendations

The wider implication for policy from the work carried out in the South of England is that more time and resource needs to be given to supporting the CCG community with practical help for implementation.

This includes developing an evidence base of the impact on patients of the use of patient decision aids and option grids, as well as assessing the impact on patient satisfaction of commissioning changes. Peer learning and clinical engagement are critical to embedding deep change in relation to shared decision making.

Working with Thames Valley HIEC

This project was carried out by the knowledge team, with project support from Pfizer Ltd and funding from NHS South of England and Pfizer Ltd. Pfizer are supporting the project as part of their commitment to work together for Britain's national health through partnership.

We can help you by:

• Involving you in the Community of Interest for shared decision making in the south of England
• Advising you on the appropriate level of support to help you meet your current CCG aims for SDM
• Signposting you to the national tools and approaches.

Thames Valley Health Knowledge Team

Contact: Email: knowledgeteam@tvhiec.org.uk

http://www.theguardian.com/healthcare-network/healthcare-innovation-partner-zone/shared-decision-making-primary-care

It’s Time for Episode-Based Health Care Spending

by Adi Kumar, Thomas Latkovic, and Daniel Tsai  |   1:00 PM October 8, 2013

There is widespread agreement that if the United States is to achieve sustainable levels of health care spending, it must make greater use of payment mechanisms that reward physicians, hospitals, and health systems for the results achieved. The vexing question is how best to make this transition.

Today, payers and providers are using a range of strategies to accomplish this goal, including patient-centered medical homes, value-based contracting, and accountable care organizations (ACOs). We applaud this trend. However, our research and experience have convinced us that the transition to outcomes-based payment will occur more easily if both payers and providers take an intermediate step and make greater use of retrospective episode-based payment (REBP).

REBP focuses on “episodes of care” (any clinical situations that have relatively predictable start and end points such as procedures, hospitalizations, acute outpatient care, and some treatments for cancer and behavioral health conditions). REBP identifies which provider is in the best position to affect the clinical outcomes and total costs associated with an episode of care; it then assesses (through retrospective analysis of claims data) the outcomes achieved and costs incurred during each episode over a specific period of time (e.g., quarterly). The identified providers are then rewarded or penalized based on their average performance across all the episodes.

The desire to jump straight to outcomes-based payment models focused on the total cost of care for an entire population has led many payers and providers to overlook, or give up on, episode-based payment. We believe it is worth reconsidering.

The Advantages

REBP offers a number of advantages. For example, because it uses the current fee-for-services claims system as its administrative platform, it does not require providers to make significant investments in new infrastructure or establish new contractual arrangements with other providers. And because it focuses on acute episodes, REBP acts as a necessary complement to payment and care-delivery models designed to improve prevention and chronic-care management. Furthermore, administering and/or participating in an REBP model can help both payers and providers develop many of the capabilities they will need for total-cost-of-care management. In short, REBP can serve as a bridge to more comprehensive total-cost-of-care approaches.

How Does REPB Work?

In the U.S. health system today, a dozen or more providers may be involved in an episode of care, and each provider typically bills separately. None of these providers is rewarded financially for helping ensure that the desired clinical outcome is delivered with the highest quality at lowest cost across the entire episode.

REBP is designed to change that. It is somewhat similar to and shares many of the same goals as the “prospective bundled payment” approach, which calls for making a single payment (or budget) to the accountable provider for all the services used to treat each specific episode for each specific patient. But key differences in design and administration make REBP more scalable in the current U.S. health system.

The six core steps required to implement REBP are listed in the exhibit “Steps Required to Implement REPB.”

Why Should Payers Pursue REBP?

Our analysis of data from private insurers, Medicaid, and Medicare suggests that 50% to 70% of all health care spending could be included within episodes of care. REBP establishes end-to-end accountability for more than half that spending.

REBP also gives payers a direct way to incentivize providers to reduce health care waste. We have consistently observed that some providers deliver the same or better clinical outcomes at dramatically lower costs than other providers in the same market. The exhibit “Average Cost Per Episode Varies Significantly Across Providers” illustrates variations in average, total per-patient costs for three different episodes in three different states. Even after we excluded patients with certain complicated conditions and adjusted for patient severity, the average cost per episode in each market still varied from 60% to over 300%. Further analysis showed that much of this variation could be explained by differences in practice patterns (e.g., decisions about device selection, diagnostics use, discharge planning, hospital admission).

REBP also offers a quick path forward, because it requires only modest additional infrastructure. We have seen multiple payers define and implement the necessary infrastructure within six months of when they agreed on an episode’s definition. Turnkey analytic vendors are also beginning to emerge.

In addition, REBP gives payers considerable strategic flexibility. Many REBP parameters can be adapted to address local conditions, align with network and member-engagement approaches, and strengthen competitive advantage. Among these parameters are cost thresholds, stop-loss provisions, the degree of gain- and risk-sharing, whether and how to normalize unit prices, and whether to steer members to certain providers.

Finally, REBP gives payers a way to prepare for the future, when episode-based performance management is likely to be a required capability. Most providers do not have access to sufficient claims data to assess performance on their own. If providers are to accept partial or total cost-of-care accountability, payers will need to offer them a performance-management infrastructure to understand clinical outcomes and costs.

Why Should Providers Pursue REBP?

If contractual terms are fair, REBP can deliver meaningful value to acute-care providers in particular. For example, it has the potential to give them a net increase in margin, because many of the sources of savings are either variable costs to these providers (e.g., implantable devices, extra care required for surgical complications) or are associated with upstream or downstream providers (e.g., pharmaceuticals, physical therapy, skilled nursing facility care). REBP can also help acute-care providers reinforce and accelerate existing strategic priorities, such as improving how hospitals influence and partner with physicians, increase adoption of clinical pathways, and reduce input costs.

REBP empowers all accountable providers by reducing the need for payers to monitor clinical decision making (e.g., through preauthorization). It also positions them to assume a stronger role in influencing the performance of upstream and downstream providers.

Strong episode performance has the potential to strengthen a provider’s value proposition to patients, employers, and payers. It may also be grounds for negotiating a stronger network position.

Furthermore, REBP requires providers to make only small, if any, investments in new infrastructure — at least initially. And it will enable them to strengthen their ability to understand end-to-end performance, a capability any providers considering more holistic total-cost-of-care payment models will need.

What Changes Must Payers Make?

To implement REBP at scale, most payers will have to shift their focus from prospective to retrospective models in most markets. Doing so will enable payers to simplify their infrastructure and focus on analytic processes that are separate from claims adjudication. This infrastructure is less invasive, requires less investment, and offers faster time-to-market than do solutions that necessitate material changes to claims-adjudication processes.

Second, payers will need to develop greater technical sophistication to ensure fairness (e.g., through episode-specific risk adjustments) and provider acceptance. They will also have to develop or adopt new standards as they emerge. The Center for Medicare and Medicaid Innovation’s efforts to create standard episode definitions, including through the Bundled Payments for Care Improvement Initiative, are a promising starting point.)

Finally, if REBP is to succeed, payers will have to implement it at scale by promoting REBP, whenever possible, across all books of business and all network providers. Most payers should also strongly consider participating in multi-payer efforts to set standards to help overcome common barriers to implementation.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here. 

http://blogs.hbr.org/2013/10/its-time-for-episode-based-health-care-spending/

Patient-centered medical home philosophy boosts patient, physician satisfaction

UCLA-USC intervention could encourage more new docs to enter primary care

By Enrique Rivero October 08, 2013

The common refrain about health care is that it's a broken system. A new joint program between UCLA and USC demonstrates a way to mend the system with a new patient-centered program that is getting rave reviews from patients and from the residents and nurses who provide their care.

 

The program, Galaxy Health, debuted at Los Angeles County+USC Medical Center in 2012 with the goal of substantially improving an on-site clinic for residents and demonstrating to county officials that intuitive and inexpensive interventions can dramatically improve patient care and physician and staff morale.

 

A new UCLA–USC study published online in the JAMA Internal Medicine, a peer-reviewed journal of the American Medical Association, outlines how the Galaxy model works in a public setting, with a favorable effect on both patients and medical residents.

 

"We all know that fewer and fewer young physicians are choosing careers in primary care because of the difficult work schedules, lack of support and lower salaries," said lead study author Dr. Michael Hochman, who conducted the research as a Robert Wood Johnson Clinical Scholar in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. "What we did here was to move in the direction of a team-based approach, and it resulted in improved satisfaction for physicians-in-training with their primary care experiences."

 

Dr. David Goldstein, an associate professor of clinical medicine at USC's Keck School of Medicine and chief of the division of geriatric, hospital, palliative and general internal medicine at LAC+USC Medical Center, was the study's senior author. He conceived the Galaxy Health program.

 

"My hope was that Galaxy would reveal that a minimal investment and reorientation in delivery focused on the patient and enhanced access to care could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment," he said. "I think it worked out well. It's not rocket science."

 

The Galaxy model established round-the-clock, seven-day-a-week access to physicians, made urgent clinic appointments available within hours and coordinated care in the ambulatory environment. It was based in part on increasing interest in a concept known as the patient-centered "medical home," which provides a team-based, coordinated approach to care that aims to make the primary care team central to the patient’s health needs. While the concept may not sound that different from the traditional vision of high-quality primary care, Galaxy's innovation is making this vision a reality in a complex, disconnected health care system.

 

"Galaxy Health has proven its value and effectiveness, as measured by patient satisfaction, access to care and provider satisfaction, in an incredibly challenging clinical environment," said Christina Ghaly, interim CEO of LAC+USC Medical Center. "Its remarkable success is to the benefit of our patients at LAC+USC Medical Center and can be a model for other safety-net, resident-run clinics struggling with implementing patient-centered medical homes."

 

The project was funded primarily by a three-year, $750,000 grant from UniHealth Foundation.

 

The study findings also support further investment in primary care, particularly in teaching settings, where the next generation of primary care leaders will be developed, said Hochman, now medical director for innovation at AltaMed Health Services, a large federally qualified health center in Southern California. There is currently a shortage of primary care physicians, and the situation is expected to become more acute as baby boomers continue to reach retirement age.

 

The researchers conducted their study at three primary-care internal medicine clinics at LAC+USC, an urban academic medical center serving a safety-net population. They focused on expanded access to care, enhanced care coordination and team-based care. Galaxy Health included the creation of a call center staffed by two care coordinators, telephone renewal of prescriptions and the availability of up to five urgent care appointments each day.

 

Input from patients and staff during prior focus groups was incorporated into the study. The researchers surveyed patients and residents before the intervention and again one year later. They also analyzed emergency room and hospital visit rates.

 

Though the clinics did not satisfy all the elements needed to qualify as a patient-centered medical home, overall their score jumped from a previous 35 to 53 out of 100 possible points. The satisfaction rating from patients increased from 48 percent to 65 percent in the intervention clinic, compared with a jump from 50 percent to 59 percent in the controls. Patients were particularly pleased with access. Satisfaction with urgent appointment scheduling increased from 12 percent to 53 percent in the intervention clinic, compared with an increase from 14 percent to 18 percent in the control clinic. 

 

The composite satisfaction score for residents went up from 39 percent to 51 percent in the intervention clinic but fell in the control clinic from 46 percent to 42 percent.

 

The study noted that emergency room and hospital visits were not reduced.

 

"This was an anticipated finding, because we expanded access to care to an underserved patient population, and frequently when this happens, there's a spike in emergency and hospital room utilization," said study co-author Dr. Arek Jibilian, assistant professor of clinical medicine in the Keck School's division of geriatric, hospital, palliative and general internal medicine. "However, we believe that a sustained commitment to primary care will ultimately reduce emergency and hospital utilization, and this is something we hope to see as the program continues."

 

Study co-authors are Steven Asch, Arek Jibilian, Bharat Chaudry, Ron Ben-Ari, Eric Hsieh, Margaret Berumen, Shahrod Mokhtari, Mohamad Raad, Elisabeth Hicks, Crystal Sanford, Norma Aguirre, Chi-hong Tseng, Sitaram Vangala and Carol M. Mangione. Additional contributors include Becky O'Neal and Roman Corral.

 

The demonstration was primarily funded by the UniHealth Foundation in Los Angeles. In addition, the study was funded by grants from the Robert Wood Johnson Clinical Scholars Program; the U.S. Department of Veterans Affairs (grant 67799 to UCLA); the UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684; and the NIH/NCATS UCLA CTSI (grant UL1TR000124).

 

The Keck School of Medicine of USC , founded in 1885, is among the nation's leaders in innovative patient care, scientific discovery, education and community service. It is part of Keck Medicine of USC, the university's medical enterprise, one of two USC-owned academic medical centers in the Los Angeles area. This includes the Keck Medical Center of USC, composed of the Keck Hospital of USC and the USC Norris Cancer Hospital. The two world-class, USC-owned hospitals are staffed by more than 500 physicians who are faculty at the Keck School. The school today has more than 1,500 full-time faculty members and voluntary faculty of more than 2,400 physicians. These faculty direct the education of approximately 700 medical students and 1,000 students pursuing graduate and postgraduate degrees. The school trains more than 900 resident physicians in more than 50 specialty or sub-specialty programs and is the largest educator of physicians practicing in Southern California. Together, the school's faculty and residents serve more than 1.5 million patients each year at Keck Hospital of USC and USC Norris Cancer Hospital, as well as the USC-affiliated Children's Hospital Los Angeles and Los Angeles County+USC Medical Center. Keck School faculty also conduct research and teach at several research centers and institutes, including the USC Norris Comprehensive Cancer Center, the Zilkha Neurogenetic Institute, the Eli and Edythe Broad Center for Stem Cell Research and Regenerative Medicine at USC, the USC Cardiovascular Thoracic Institute, the USC Eye Institute and the USC Institute of Urology.

 

General Internal Medicine and Health Services Research is a division within the department of medicine at the David Geffen School of Medicine at UCLA. It provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division's 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor–patient communication. The division's researchers have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp. and Charles Drew University.

 

The Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policymakers on issues important to the health and well-being of all Americans. This program is supported in part through a collaboration with the U.S. Department of Veterans Affairs.

http://newsroom.ucla.edu/portal/ucla/patient-centered-medical-home-248773.aspx

Mobile health vans' value proposition

Posted on Sep 13, 2013

By Tammy Worth, Contributing Writer

Hospitals that utilize mobile health vans will tell anyone that bringing needed services to people in underserved areas improves population health, but with accountability and cost effectiveness increasingly important, there is a need to understand the potential financial return on this kind of service.
While no one doubts that the vans bringing primary care or focused services like dental care or preventive screenings do so for no cost or very low cost, there is not a lot of data available to pinpoint just how valuable the mobile health service is to hospitals.
Part of the challenge with determining the return on investment of mobile health units is inherent to their use. Unlike most hospital services, the goal of mobile health is to find and care for people who can’t pay for treatment.
“St. Joe is very mission-based and we are looking for people who are low-income, uninsured and would otherwise not be able to access this kind of care,” said Dana Codron, executive director of community outreach at St. Joseph Health in Napa, Calif.
St. Joseph invests $5 million annually in mobile health clinics, about 11 percent of which is offset by reimbursements. Their mobile dental clinics, which cost about $650,000 annually to operate, are reimbursed better and see about 60 percent of costs returned.
“We anticipate a loss but we do believe it is possible to generate revenue and meet expenses if the target population is better insured,” Codron said.
Southcoast Health System’s mobile health system is also in the red, but the vans, which serve communities in southeastern Massachusetts and East Bay, Rhode Island, fill a void in those communities, said Kerry Mello, community benefits manager for the organization.
“If we put an article in the paper saying we were doing free screenings, we would get few people to come out,” she said. Having the mobile health vans allows the nonprofit hospital to go directly to the people in their communities, potentially saving lives and money down the road.
Many nonprofits like Southcoast and St. Joseph have funds set aside for mobile vans as part of their community benefit requirements.
At St. Joseph, 10 percent of net revenue and 1.5 percent of the operational budget is linked to services that care for underserved populations, Codron said. They also receive grants to offset some of the costs of the vans. Many mobile health units rely upon this kind of mixed funding for operations.
Part of the challenge of funding mobile health vans at for-profits is that, as an accounting line item, the units don’t make money. Similar to the argument for preventive services in general, the cost savings are indirect. There is an assumption that mobile units will reduce the instance of emergency room visits and keep chronic conditions from advancing to the degree where patients need higher-cost care.
Though the numbers on savings related to prevention are drastically varied depending upon their source, Trust for America’s Health has shown a return of $5.60 for every $1 spent on prevention. This is mostly found in reducing rates of diseases that can be caused by poor lifestyle habits including type 2 diabetes, high blood pressure, heart disease and some cancers.
Some groups have tried to quantify the return on investments on these mobile health units and their calculations are positive.
“We had to prove that they aren’t just improving health, but there is a financial benefit, too,” said Jennifer Bennett, executive director of the Family Van program based at Harvard Medical School.
Bennett and colleagues worked with a formula to understand the financial viability of mobile health vans. The return on investment is equal to the value of the van divided by the annual cost to run it (i.e. emergency department costs avoided plus the value of life years saved from the services provided).
Based on data provided in 2008 from Boston vans, they figured that the saved cost of emergency visits was more than $3 million and the value of providing preventive services was approximately $20 million a year. The cost to run the program was $567,700. The ROI was $36 for every $1 spent.
Another program, a group of mobile asthma clinics called the Breathmobile, provides free care to underserved children in different cities across the nation. A study of Breathmobile use in Baltimore found that after a year in the program, $79.43 was saved for patients each day they were symptom free. A study of Breathmobiles in California found an ROI of $6.73 per $1 invested. They added the emergency room costs avoided and the value of quality-adjusted life years saved and divided it by the cost of the program, which was approximately $500,000 a year.
One of the reasons the cost benefits are so high is that the mobile clinics tend to serve high-risk populations that are high users of emergency departments, Bennett said. One question her group asked when they were creating the study was what patients would have done if they hadn’t visited the Family Van the day they did. Fifty-four percent said they would have gone to an emergency room.
“The establishment benefiting the most is not the Breathmobile itself in terms of dollars, but it is going to be the public health insurance system,” said Tricia Morphew, an analyst for Breathmobile. “They are able to spend less in emergency department and hospital visits.”

http://www.healthcarefinancenews.com/news/mobile-health-vans-value-proposition

ASC: 100 Surgery Center Benchmarks & Statistics to Know

Here are 100 benchmarks and statistics for ambulatory surgery centers based on reports from Accreditation Association for Ambulatory Health Care, Ambulatory Surgical Centers of America, Ambulatory Surgery Center Association, HealthCare Appraisers, Provista, RemitData, MedPAC, Objective Health and VMG Health. 

All benchmarks and statistics on this list are averages gathered by compiling data from multiple ASCs.

Operational benchmarks

1. Administrator salary is $109,184. ¹

2. Administrators in the west receive the highest salary, at $114,109 while administrators in the Midwest receive the lowest salary at $104,317.

3. Staff hours per case at ASCs is 12.8 hours.

4. Administrative hours per case is four hours.

5. Nurse hours per case in one- to two-OR centers is 5.2 hours.

6. Administrative hours at one- to two-OR centers is 3.8 hours.

7. Nurse hours at ASCs with three- to four-ORs is 6.3 hours.

8. Administrative hours at ASCs with three- to four-ORs is 4.1 hours.

9. ASCOA surgery centers have a per room goal of 10 cases per day to encourage compressed schedules. ²

10. GI and pain-driven centers with less than five clinical hours would have a total of around eight staff hours per case.

11. Centers with more complicated cases such as orthopedics and spine would have clinical hours around seven to eight hours per case and total staff hours around 10 to 12 hours per case.

12. Average room turnover time goal is seven to 10 minutes at ASCOA surgery centers, depending on the case mix.

13. 53 percent of ambulatory surgery centers maintain paper records and 23 percent track their supply chain on spreadsheets. ³

14. Typical surgery centers have 19 cases per day. ⁴

15. 74 percent of the cases are performed by the top five physicians at the ASC.

16. ASCs have of three surgical cases per operating room per day.

17. Total operating expenses per OR is $1.2 million.

18. Employee salary and wages per operating room is $421,820.

19. Medical and surgical expenses per OR are $375.37.

20. General and administrative expenses per OR are $259.38.

21. Total cases per center is 4,714 per year.

22. Average number of non-surgical cases per year is 1,146.

23. 765 cases are performed per operating room annually, with 4.6 cases per day.

24. ASC procedure rooms see around 1,144 non-surgical cases per room annually, with 4.6 procedures per day.

25. The top five physicians performed 54 percent of the ASC's case volume.

26. Surgery centers with more than four operating rooms performed 24 cases per day, while those with one to two operating rooms performed 12 cases per day.

27. Surgery centers with one to two operating rooms had the highest annual surgical case rate per operating room, at 782, while those with more than four operating rooms hosted 744 cases annually per operating room. 

28. Non-surgical case volume per year at facilities with one to two operating rooms is 1,017 cases per procedure room.

29. Surgery centers with three to four ORs reported 769 non-surgical cases per procedure room annually, which dropped to 705 cases in centers with more than four ORs.

30. In surgery centers with more than four ORs, only 22 percent of the cases were performed by the top two physicians, while 62 percent were performed by the top 10 physicians.

31. Median operating room time per patient encounter: 50.2 minutes. ⁵

32. Procedure room time per patient encounter: 34.2 minutes.

33. Median rate of unscheduled direct transfers: .6 transfers per 1,000 patient encounters.

34. 34 percent of ASC leaders plan to standardize products used in their center. ⁶

35. 24 percent plan to evaluate their GPO.

36. 19 percent plan to implement an order management system.

37. 6 percent plan to change or join a GPO.

38. 6 percent plan to change distributors.

Revenue cycle benchmarks

39. 79.9 percent of ASCs collect between 0 to 30 days from the date of service to the check date. ⁷

40. 13.3 percent of ASCs receive cash collection between 31 and 60 days from the service date to the check date. 

41. 20 percent of ASC claims are not collected for more than 30 days. ⁸

42. The top reason for ASC procedures to receive an unexpected denial is "claims or service lacks information which is needed for adjudication." The second most common reason is "duplicate claim or service" followed by "procedure or treatment is deemed experimental or investigational by the payer." 

43. Commercial insurance companies have a 12 percent unexpected denial rate for the top 10 CPT codes that have unexpected denials at ASCs.

44. Medicare's unexpected denial rate is 6 percent for the top 10 CPT codes that have unexpected denials at ASCs.

45. Medicaid has a 26 percent denial rate for the top 10 CPT codes that have unexpected denials at ASCs.

46. Around 47 percent of ASCs with fewer than 3,000 cases have 0 to 30 A/R days, while 18.7 percent have 31 to 60 A/R days. ⁹

47. Most ASCs with at least 6,000 cases annually have 0 to 30 A/R days.

48. Of all ASCs, about 15.9 percent have more than 120 A/R days.

49. For ASCs with three to four ORs, average ENT revenue is $1,734 per case.

50. Average GI/endoscopy revenue per case for medium-sized ASCs is $776.

51. Orthopedics revenue per case for three- to four-OR ASCs is $2,617.

52. Average general surgery revenue per case for medium sized ASCs is $1,721.

53. For ASCs with three to four ORs, average ophthalmology revenue is $1,249 per case.

54. Average plastic surgery revenue per case for medium-sized ASCs is $1,516.

55. Podiatry revenue per case for three- to four-OR ASCs is $2,021.

56. For medium sized ASCs, average OB/GYN revenue per case is $1,958.

57. Average pain management revenue per case for three- to four-OR ASCs is $890.

58. Revenue per case for urology procedures in medium-sized ASCs is $1,476.

59. ASCOA centers have a goal of low-to-mid 30s for A/R days out. ¹⁰

Clinical benchmarks

60. 89 percent of patients wait at least a month after scheduling cataract surgery before undergoing the procedure.¹¹

61. 96 percent of patients are able to schedule their cataract surgery at their desired time in the ASC.

62. 94 percent of patients resume daily living within a week of undergoing cataract surgery.

63. 94 percent of patients reported improved vision after cataract surgery in an ASC.

64. 98 percent of patients say they're comfortable while undergoing cataract surgery in the ASC and 99 percent are comfortable after discharge.

65. 99 percent of patients report they would recommend cataract surgery after undergoing the procedure in an ASC.

66. Pre-procedure time is 81 minutes for cataract surgeries.

67. Procedure time for cataract surgeries in ASCs is 14 minutes.

68. Discharge time for cataract surgeries is 21 minutes.

69. 77 percent of colonoscopy patients report little or no discomfort during bowel preparation. ¹²

70. 81 percent of colonoscopy patients wait less than a month between scheduling their colonoscopy and having the procedure.

71. 98 percent of colonoscopy patients report being comfortable after discharge.

72. 99 percent of colonoscopy patients report little or no discomfort during the procedure and would recommend it to others.

73. 100 percent of colonoscopy patients report understanding the procedure.

74. Colonoscopy procedure time is nine to 29 minutes.

75. Pre-procedure time for colonoscopy is 17 to 129 minutes, covering patient check-in to scope insertion.

76. Colonoscopy discharge time is 15 to 75 minutes for ASCs.

77. Pre-procedure time for knee arthroscopy is 88 minutes, and organizations with shortest times attribute results to calling patients the day before to remind them of the appointment and pre-procedure requirements.¹³ 

78. Knee arthroscopy procedure time is 28 minutes in the ASC.

79. Discharge time for knee arthroscopy is 75 minutes in the ASC, and organizations with short discharge times attribute results to having patients leave the operating room as they are waking up to assess their comfort level as soon as possible.

80. 75 percent of knee arthroscopy patients wait less than a month for their procedure after scheduling.

81. 89 percent of knee arthroscopy patients are able to schedule the procedure as soon as they wanted in the ASC.

82. 99 percent of knee arthroscopy patients say they are comfortable post-discharge in the ASC.

83. Pre-procedure time for low back injections is 43 minutes, and organizations with the shortest discharge times attribute results to not using or using low levels of sedation or controlling the type and amount of medication administered. ⁸³

84. Procedure time is seven minutes for low back injections in the surgery center.

85. Discharge time after low back injections in the ASC is 22 minutes, with a range of one to 42 minutes.

86. 90 percent of patients wait less than a month from scheduling their low back injection to undergoing the procedure in the ASC.

87. 93 percent of patients say they are able to schedule their low back injections in an ASC within a "reasonable" period to time.

88. 85 percent of patients report returning to daily activities after undergoing low back injections in ASCs.

89. 80 percent of patients say they experienced less pain after the low back injections, and 50 percent reduced pain medications after the procedure.

Growth benchmarks

90. 100 percent of surgery center management companies in the HealthCare Appraisers 2013 ASC Valuation Survey found orthopedics/sports medicine a desirable specialty. ¹⁵

91. 94 percent of ASC management companies find orthopedic spine a desirable specialty in 2013.

92. 94 percent of ASC management companies find ENT desirable in 2013.

93. 88 percent of ASC management companies find general surgery desirable in 2013

94. 88 percent of ASC management companies find pain management desirable in 2013.

95. 82 percent of ASC management companies find gastroenterology a desirable specialty in 2013.¹⁶

96. There were 113 new Medicare-certified ambulatory surgery centers in 2012. 

97. Medicare made $3.5 billion in payments to ambulatory surgery centers in 2011.

98. There were 5,344 Medciare-certified ambulatory surgery centers in 2011, up 1.8 percent over the previous year.¹⁷

99. Between 2001 and 2011, the number of ambulatory surgery center operating rooms doubled in the United States and in 2011, 60 percent of hospitals had an ASC within five minutes of their facility. ¹⁸ 

100. Objective Health predicts that procedure volumes for cases such as shoulder arthroscopy, which Medicare paid ASCs 42 percent lower than hospital outpatient departments in 2012, will continue to increase in ASCs.

http://www.beckersasc.com/lists/100-surgery-center-benchmarks-statistics-to-know.html