Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience

Umesh N Khot, Michele L Johnson-Wood, Jason B Geddes, Curtis Ramsey, Monica B Khot, Heather Taillon, Randall Todd, Saeed R Shaikh, William J Berg, Umesh N Khot, Michele L Johnson-Wood, Jason B Geddes, Curtis Ramsey, Monica B Khot, Heather Taillon, Randall Todd, Saeed R Shaikh, William J Berg

Abstract

Background: The impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown.

Methods: We prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004-August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005-June 26, 2006 after protocol implementation.

Results: Per hospital admission, insurance payments (hospital revenue) decreased ($35,043 +/- $36,670 vs. $25,329 +/- $16,185, P = 0.039) along with total hospital costs ($28,082 +/- $31,453 vs. $18,195 +/- $9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs. $7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped $1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 +/- $74,033 vs. $53,514 +/- $23,378, P = 0.059), diagnosis related group relative weight (3.7479 +/- 2.6731 vs. 2.9729 +/- 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 +/- $53,741 vs. $35,937 +/- $23,125, P = 0.044; Total hospital costs: $39,974 +/- $37,434 vs. $26,778 +/- $15,561, P = 0.007; Net Income: $9984 vs. $9159, P = 0.855.

Conclusion: All of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up.

Trial registration: ClinicalTrials.gov ID: NCT00800163.

Figures

Figure 1
Figure 1
Outlier payments defined as hospital charges>$100,000 and hospital revenue>$100,000 both decreased significantly with adoption of the ED Activation/Immediate Transfer process.
Figure 2
Figure 2
Wide variation in payments from Medicare for ST-elevation myocardial infarction despite prospective payment system. It is widely assumed that payments from Medicare are "fixed" due to prospective payment system. However, a patient presenting with ST-elevation myocardial infarction can have a wide variety of clinical events, which ultimately determine the assigned DRG, and can lead to a nearly 20-fold variation in payment from Medicare. Addition of payments from the outlier payment system can lead to even larger variations in hospital revenue. (Fiscal 2007 Medicare DRG Relative Weights and 2007 St. Francis Heart Center base rate of $5,238)
Figure 3
Figure 3
Relationship between total hospital costs and insurance payments (hospital revenue) for study cohort. There was a linear relationship between total hospital costs and insurance payments (hospital revenue); for every $1,000 reduction in total hospital costs, there was $1,009 reduction in insurance payments (hospital revenue). Thus, even with a significant proportion of patients treated by prospective payment (Medicare/Medicaid), there remains a strong relationship between costs and revenue. Dashed lines are 95% confidence intervals.
Figure 4
Figure 4
Time course of financial outcomes from payer and hospital perspective. (A) After the index hospitalization, there was a more than $10,000 reduction in insurance payments (hospital revenue) per patient. (B) After one year of follow-up, the reduction in insurance payments (hospital revenue) increased to greater than $14,000 per patient. (C) Despite marked improvement in hospital cost structure (Tables 1 and 3), hospital net income showed a slight numerical decrease as the decrease in revenue exceeded the cost reductions. Post-discharge one-year financial data include both outpatient and inpatient hospital encounters.

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Source: PubMed

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