To hospitals, billions of dollars depend on how they define a patient's stay. Even though a patient may be in the hospital for a simple surgery, Medicare might classify the procedure as outpatient care and pay a lower fee to the hospital. Or someone may come into the emergency room complaining of chest pain but leave after just a day or two, once the tests have ruled out a heart attack. Does that qualify as an inpatient stay at a higher Medicare payment? With government auditors and contractors cracking down on hospitals for what they contend are overbilling practices, hospitals are paying more and more attention to how they classify care when filing claims to Medicare, the federal health insurance program.
Federally funded programs will add at least 2,300 new primary care practitioners by the end of 2015, but the funding for at least one of those programs is set to expire at the same time, contributing to a massive shortage of doctors available to treat patients — including those newly insured through the Affordable Care Act and Medicare. The U.S. is expected to need 52,000 more primary care physicians by 2025, according to a study by the Robert Graham Center, which does family medicine policy research. But funding for teaching hospitals that could train thousands more of these doctors expires in late 2015.
Today, the Utah health system is one of a handful in the nation with a data system that can track cost and quality for every one of its 26,000 patients. That data is shared with doctors and nurses for further input about ways to streamline cost and improve care. In the first year, the system shaved nearly $2.5 million from a $1 billion budget, and officials say they're in a better position to negotiate with insurers because they know precisely how much it costs to perform a particular procedure.
Analyzing big data can predict patients' future risk of metabolic syndrome and allow individuals and clinicians to work together on preventative steps that save lives and money. While organizations have used a lot of big data projects to discern trends, a study conducted by Aetna and GNS Healthcare analyzed data from almost 37,000 members of an Aetna employer customer who opted in for screening of metabolic syndrome -- which can lead to chronic heart disease, stroke, and diabetes. GNS analyzed information such as medical claims records, demographics, pharmacy claims, lab tests, and biometric screening results from a two-year period.
Massachusetts General Hospital will take the unusual step of questioning all patients about their use of alcohol and illegal drugs beginning this fall, whether they are checking in for knee surgery or visiting the emergency department with the flu. How often have you had six or more drinks on one occasion, caregivers will ask, or used an illegal drug in the past year? If the battery of four questions reveals a possible addiction, doctors can summon a special team to conduct a "bedside intervention" and, if needed, arrange treatment. The mandatory screening program is part of a broad plan to improve addiction treatment at the Boston teaching hospital and its community health centers and is an example of an expanding national and statewide effort to reach substance abusers earlier and in mainstream medical settings.
If you offer it, will they come? Insurers and some U.S. senators have proposed offering cheaper, skimpier ?copper? plans on the health insurance marketplaces to encourage uninsured stragglers to buy. But consumer advocates and some policy experts say that focusing on reducing costs on the front end exposes consumers to unacceptably high out-of-pocket costs if they get sick. The trade-off, they say, may not be worth it. Coverage on the health insurance marketplaces now is divided into five types of plans that require different levels of cost-sharing by consumers. All the plans cover 10 so-called essential health benefits, including hospitalization, drugs and doctor visits. Preventive care is covered without any cost-sharing.