Majority of hospitals not meeting minimum volumes for high-risk surgeries, Leapfrog says

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The majority of hospitals are electively performing high-risk surgical procedures without sufficient ongoing experience to safely do so, according to a new report.

The report from The Leapfrog Group, an independent hospital safety watchdog group, looked specifically at surgical volumes. The report, which relied on final hospital data from the 2019 Leapfrog Hospital Survey that had responses from more than 2,100 hospitals, also looked at the minimum standards those hospitals require surgeons to meet in order to gain privileges.

They were looking specifically at the safety of eight high-risk procedures identified by an expert panel as having a “strong volume-outcome relationship.” The report also looks at whether hospitals are working to make sure every surgery is necessary. 

According to the report, an increasing number of hospitals are meeting minimum volume standards if they perform high-risk hospitals. The majority of rural hospitals opt out of performing the high-risk surgeries because they can’t meet the volume standards. Further, more hospitals are implementing protocols to monitor for appropriateness of surgeries.

“The good news is we are seeing progress on surgical safety. The bad news is the vast majority of hospitals performing these high-risk procedures are not meeting clear volume standards for safety,” said Leah Binder, president and CEO of The Leapfrog Group, in a statement. “This is very disturbing, as a mountain of studies show us that patient risk of complications or death is dramatically higher in low-volume operating rooms.”

For instance, the report suggested hospitals should be performing a minimum of 20 esophageal resections for cancer and a minimum of 20 pancreatic resections for cancer to improve the odds of a safer surgery for their patients. Surgeons should perform at least seven and 10 of those procedures a year, respectively, to gain privileges.

But for those two procedures, only 3% and 8% of hospitals met the volume standards for patient safety, the report found.

Hospitals were most likely to meet the safety standard of a minimum of 50 procedures a year for the hospital and 20 procedures a year for bariatric surgery for weight loss. More than 48% reported meeting that standard in 2019, up from 38% in 2018.

The survey found more than 70% of reporting hospitals have protocols to ensure appropriateness for cancer procedures.

But for other high-risk procedures evaluated such as open-heart surgeries or mitral valve repair and replacement, hospital compliance with ensuring appropriateness dropped to a range of 32% to 60%, depending on the procedure.




110 hospital benchmarks | 2020

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Hospitals across the nation compete in a number of ways, including on quality of care and price, and many use benchmarking to determine the top priorities for improvement. The continuous benchmarking process allows hospital executives to see how their organizations stack up against regional competitors as well as national leaders.

Becker’s Hospital Review has collected benchmarks related to some of the most important day-to-day areas hospital executives oversee: quality, finance, staffing and utilization.


Key ratios

Source: Moody’s Investors Service, “Not-for-profit and public healthcare – US: Medians” report, September 2019. 

The medians are based on an analysis of audited fiscal 2018 financial statements for 284 freestanding hospitals, single-state health systems and multistate health systems, representing 79 percent of all Moody’s-rated healthcare entities. Children’s hospitals, hospitals for which five years of data are not available and certain specialty hospitals were not eligible for inclusion in the medians.

1. Maintained bed occupancy: 66.6 percent

2. Operating margin: 1.8 percent

3. Excess margin: 4.3 percent

4. Operating cash flow margin: 7.9 percent

5. Return on assets: 3.6 percent

6. Three-year operating revenue CAGR: 5.6 percent

7. Three-year operating expense CAGR: 6.4 percent

8. Cash on hand: 200.9 days

9. Annual operating revenue growth rate: 5.5 percent

10. Annual operating expense growth rate: 5.4 percent

11. Total debt-to-capitalization: 33.7 percent

12. Total debt-to-operating revenue: 33.3 percent

13. Current ratio: 1.9x

14. Cushion ratio: 21.6x

15. Annual debt service coverage: 4.7x

16. Maximum annual debt service coverage: 4.4x

17. Debt-to-cash flow: 3.1x

18. Capital spending ratio: 1.2x

19. Accounts receivable: 45.9 days

20. Average payment period: 61.4 days

21. Average age of plant: 11.7 years

Hospital margins by credit rating group

Source: S&P Global Ratings “U.S. Not-For-Profit Health Care System Median Financial Ratios — 2018 vs. 2017” report, September 2019.

AA+ rating

22. Operating margin: 5.5 percent

23. Operating EBIDA margin: 12 percent

24. Excess margin: 9.2 percent

25. EBIDA margin: 14.8 percent

AA rating

26. Operating margin: 4.4 percent

27. Operating EBIDA margin: 10.1 percent

28. Excess margin: 6.7 percent

29. EBIDA margin: 12.4 percent

AA- rating

30. Operating margin: 3.4 percent

31. Operating EBIDA margin: 9.5 percent

32. Excess margin: 4.0 percent

33. EBIDA margin: 10.4 percent 

A+ rating

34. Operating margin: 1.6 percent

35. Operating EBIDA margin: 7.4 percent

36. Excess margin: 3.3 percent

37. EBIDA margin: 10.1 percent 

A rating

38. Operating margin: 2.1 percent

39. Operating EBIDA margin: 7.6 percent

40. Excess margin: 3.3 percent

41. EBIDA margin: 8.6 percent

 A- rating

42. Operating margin: 1 percent

43. Operating EBIDA margin: 7.8 percent

44. Excess margin: 2.5 percent

45. EBIDA margin: 8.3 percent

Average adjusted expenses per inpatient day

Source: Kaiser State Health Facts, accessed in 2020 and based on 2018 data. 

Adjusted expenses per inpatient day include all operating and nonoperating expenses for registered U.S. community hospitals, defined as public, nonfederal, short-term general and other hospitals. The figures are an estimate of the expenses incurred in a day of inpatient care and have been adjusted higher to reflect an estimate of the volume of outpatient services.

46. Nonprofit hospitals: $2,653

47. For-profit hospitals: $2,093

48. State/local government hospitals: $2,260

Prescription drug spending

Source: NORC at the University of Chicago’s “Recent Trends in Hospital Drug Spending and Manufacturer Shortages” report, January 2019. Figures below are based on 2017 data.

49. Average prescription drug spending per adjusted admission at U.S. community hospitals: $555 

50. Average outpatient prescription drug spending per adjusted admission at U.S. community hospitals: $523

51. Average inpatient prescription drug spending per admission at U.S. community hospitals: $756

52. GPO hospital spending on Activase:  $210 million

53. GPO hospital spending on Remicade: $138 million

54. GPO hospital spending on Humira: $122 million

55. GPO hospital spending on Rituxan: $92 million

56. GPO hospital spending on Neulasta: $92 million

57. GPO hospital spending on Prolia: $85 million

58. GPO hospital spending on Harvoni: $83 million

59. GPO hospital spending on Procrit: $80 million

60: GPO hospital spending on Lexiscan: $64 million

61. GPO hospital spending on Enbrel: $60 million

Quality and process of care 

Source: Hospital Compare, HHS, Complications and Deaths-National Averages, May 2018, and Timely and Effective Care-National Averages, May 2018, the latest available data for these measures.

Hospital-acquired conditions

The following represent the average percentage of patients in the U.S. who experienced the conditions.

62. Collapsed lung due to medical treatment: 0.27 percent

63. A wound that splits open on the abdomen or pelvis after surgery: 0.95 percent

64. Accidental cuts and tears from medical treatment: 1.29 percent

65. Serious blood clots after surgery: 3.85 percent

66. Serious complications: 1 percent

67. Bloodstream infection after surgery: 5.09 percent

68. Postoperative respiratory failure rate: 7.35 percent

69. Pressure sores: 0.52 percent

70. Broken hip from a fall after surgery: 0.11 percent

71. Perioperative hemorrhage or hematoma rate: 2.53 percent

Death rates

72. Death rate for CABG surgery patients: 3.1 percent

73. Death rate for COPD patients: 8.5 percent

74. Death rate for pneumonia patients: 15.6 percent

75. Death rate for stroke patients: 13.8 percent

76. Death rate for heart attack patients: 12.9 percent

77. Death rate for heart failure patients: 11.5 percent

Outpatients with chest pain or possible heart attack

78. Median time to transfer to another facility for acute coronary intervention: 58 minutes

79. Median time before patient received an ECG: 7 minutes

Lower extremity joint replacement patients

80. Rate of complications for hip/knee replacement patients: 2.5 percent

Flu vaccination

81. Healthcare workers who received flu vaccination: 90 percent

Pregnancy and delivery care

82. Mothers whose deliveries were scheduled one to two weeks early when a scheduled delivery was not medically necessary: 2 percent

Emergency department care

83. Average time patient spent in ED after the physician decided to admit as an inpatient but before leaving the ED for the inpatient room: 103 minutes

84. Average time patient spent in the ED before being sent home: 141 minutes

85. Average time patient spent in the ED before being seen by a healthcare professional: 20 minutes

86. Percentage of patients who left the ED before being seen: 2 percent


Source: American Hospital Association “Hospital Statistics” report, 2019 Edition.

Average full-time staff

87. Hospitals with six to 24 beds: 101

88. Hospitals with 25 to 49 beds: 176

89. Hospitals with 50 to 99 beds: 302

90. Hospitals with 100 to 199 beds: 683

91. Hospitals with 200 to 299 beds: 1,264

92. Hospitals with 300 to 399 beds: 1,789

93. Hospitals with 400 to 499 beds: 2,670

94. Hospitals with 500 or more beds: 5,341

Average part-time staff

95. Hospitals with six to 24 beds: 52

96. Hospitals with 25 to 49 beds: 84

97. Hospitals with 50 to 99 beds: 141

98. Hospitals with 100 to 199 beds: 286

99. Hospitals with 200 to 299 beds: 472

100. Hospitals with 300 to 399 beds: 604

101. Hospitals with 400 to 499 beds: 1,009

102. Hospitals with 500 or more beds: 1,468


Source: American Hospital Association “Hospital Statistics” report, 2019 Edition.

Average admissions per year

103. Hospitals with six to 24 beds: 408

104. Hospitals with 25 to 49 beds: 901

105. Hospitals with 50 to 99 beds: 2,097

106. Hospitals with 100 to 199 beds: 5,809

107. Hospitals with 200 to 299 beds: 11,241

108. Hospitals with 300 to 399 beds: 16,635

109. Hospitals with 400 to 499 beds: 20,801

110. Hospitals with 500 or more beds: 34,593


Half of insured adults are skipping primary care visits. Cost a major reason why

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In a given year by 2016, almost 50 percent of adults with commercial insurance hadn’t visited a primary care physician, according to a study published in the Annals of Internal Medicine.

For the study, researchers from Harvard Medical School in Boston, the Icahn School of Medicine at Mount Sinai in New York City and the University of Pittsburgh School of Medicine wanted to better characterize primary care declines among adults. To do so, the study authors analyzed deidentified claims data from a national private insurer that covers roughly 20 million members each year, according to NPR.

They found from 2008-16, adult visits to primary care physicians fell by nearly 25 percent. The decline was largest among younger adults. The proportion of adults with no visits to primary care physicians in a given year climbed from 38.1 percent to 46.4 percent within the same period.

While the number of preventive checkups rose — likely because the ACA made the appointments cost-free — problem-based visits, such as going to a primary care physician for sickness or injury, declined more than 30 percent, according to NPR.

Problem-based visits saw out-of-pocket costs increase 31.5 percent during the study period, which could have affected the decline, according to researchers. Additionally, visits to alternative sites like urgent care clinics grew by 46.9 percent in the study period.

“Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care,” the study authors concluded. 




Seattle Children’s sues to block release of health records; top official resigns

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Seattle Children’s Hospital has filed a lawsuit to block the release of health department records regarding mold at its facility, according to court documents cited by King 5. 

The hospital’s legal team filed an amended complaint in an attempt to block the release of state and county health records.

Documents previously released to the media through a public records request revealed a nearly 20-year history of Aspergillus mold in the air handling system of the hospital’s operating rooms.

Most recently, an infant at Seattle Children’s Hospital died Feb. 12 after she developed a mold-related infection acquired at the facility, the seventh mold-related death since 2001.

The health records sought by the media are “confidential and sensitive,” Adrian Urquhart Winder, attorney for Seattle Children’s, said, according to King 5. The attorney cited a state law that says records produced for quality improvement purposes cannot be publicly disclosed.

On Jan. 10, Mark Del Beccaro, MD, former CMO and senior vice president of Seattle Children’s Hospital, resigned, according to a hospital spokesperson. King 5 could not reach Dr. Del Beccaro for comment.




Despite provider claims, hospital M&A not associated with improved care, NEJM finds

Dive Brief:

  • Hospital consolidation is associated with poorer patient experiences and doesn’t improve care, according to a study published Thursday in the New England Journal of Medicine, refuting a common provider justification for rampant mergers and acquisitions.
  • The study funded by HHS’ health quality research division, the Agency for Healthcare Research and Quality, found that acquired hospitals saw moderately worse patient experience, along with no change in 30-day mortality or readmission rates. ​Acquired hospitals did improve slightly in clinical process, though that can’t be directly chalked up to the results of an acquisition, researchers found.
  • It’s further evidence that bigger isn’t always better when it comes to hospitals, and adds onto a heap of previous studies showing provider mergers lead to higher prices for commercially insured patients.

Dive Insight:

Hospitals continue to turn to M&A to navigate tricky industry headwinds, including lowering reimbursement and flatlining admissions as patients increasingly turn to alternate, cheaper sites of care. Provider trade associations maintain consolidation lowers costs and improves operations, which trickles down to better care for patients.

Though volume of deals has ebbed and flowed, hospital M&A overall has steadily increased over the past decade. The hospital sector in 2018 saw 90 deals, according to consultancy Kaufman Hall, up 80% from just 50 such transactions in 2009.

Thursday’s study analyzed CMS data on hospital quality and Medicare claims from 2007 through 2016 and data on hospital M&A from 2009 to 2013 to look at hospital performance before and after acquisition, compared with a control group that didn’t see a change in ownership.

American Hospital Association General Counsel Melinda Hatton took aim at the study’s methods to refute its findings, especially its reliance on a common measure of patient experience called HCAHPS.

“Using data collected from patients to make claims about quality fails to recognize that it is often incomplete, as patients are not required to and do not always respond comprehensively,” Hatton told Healthcare Dive in a statement. “The survey does not capture information on the critical aspects of care as it is delivered today.”

The results contradict a widely decried AHA-funded study last year conducted by Charles River Associates that found consolidation improves quality and lowers revenue per admission in the first year prior to integration. The research came quickly under fire by academics and patient advocates over potential cherrypicked results.

A spate of previous studies found hospital tie-ups raise the price tag of care on payers and patients. Congressional advisory group MedPAC found both vertical and horizontal provider consolidation are correlated with higher healthcare costs, the brunt of which is often borne by consumers in the form of higher premiums and out-of-pocket costs.

A 2018 study published in the Quarterly Journal of Economics found prices rose 6% after hospitals were acquired, partially due to limiting market competition. Groups like the left-leaning Center for American Progress have called for increased scrutiny from antitrust regulators as a result, but — despite snowballing M&A — there’s been little change in antitrust regulation since the 1980s. The Federal Trade Commission won several challenges to hospital consolidation in the 2010s, but the agency only contests 2% to 3% of mergers annually, according to MedPAC analysts.

Providers, like most actors across the healthcare ecosystem, are increasingly under fire for high prices and predatory billing practices. President Donald Trump’s administration finalized a rule late last year that would force hospitals to reveal secret negotiated rates with insurers, relying on the assumption that transparency would shame both actors into lowering prices.

A cadre of provider groups led by the AHA sued HHS over the regulation, arguing it violates the First Amendment and would place undue burden on hospitals, while potentially stifling competition. The lawsuit is currently being reviewed by the U.S. District Court for the District of Columbia.




Hospital M&A spurs rising healthcare costs, MedPAC finds

Dive Brief:

  • Both vertical and horizontal hospital consolidation is correlated with higher healthcare costs, according to a congressional advisory committee on Medicare, in yet another study finding rampant mergers and acquisitions drive up prices for consumers.
  • The Medicare Payment Advisory Commission found providers with greater market share see higher commercial profit margins, leading to higher costs per discharge, though the direct relationship between market share and cost per discharge was not statistically meaningful itself.
  • MedPAC also found vertical integration between health systems and physician practices increases prices and spending for consumers. The top-down consolidation leads to higher prices for commercial payers and Medicare alike, as hospitals have more bargaining heft and benefit from Medicare’s payment hikes for hospital outpatient departments.

Dive Insight:

Hospital consolidation has become a major point of concern for policymakers, antitrust regulators and patient advocacy groups.slew of prior studies have found unchecked provider M&A contributes to higher healthcare costs, with the brunt often borne by consumers in the form of higher premiums and out-of-pocket costs.

Since 2003, the number of “super-concentrated” markets has increased from 47% to 57%, according to the MedPAC analysis of CMS and American Hospital Association data. Those markets, with a high amount of consolidation, rarely see new providers enter, which stifles competition, and are rarely reviewed by the government.

There’s been little change in antitrust regulation since the 1980s and, though the Federal Trade Commission has won several challenges to hospital consolidation in the 2010s, the agency only challenges 2% to 3% of mergers annually.

MedPAC also found super-concentrated insurance markets actually led to lower costs per discharge compared to lower levels of payer concentration, deflating somewhat hospital lobbies’ arguments that payer consolidation is driving prices higher.

Committee members called for more analysis of how macro trends like an aging population and federal policy could be driving consolidation and impacting prices, leading some to call for a revamp of the hospital payment framework itself.

“We have to change the way hospitals are paid. I don’t see another solution,” said Brian DeBusk, CEO of Tennesse-based DeRoyal Industries, a medical manufacturer. “Are you going to undo a thousand hospital mergers? Are you going to enact rate setting? I don’t see another way.”

MedPAC also looked at vertical integration, where hospitals snap up physicians practices downstream. According to the Physician Advocacy Institute, only 26% of physician practices were owned by hospitals in 2012, but by last year that number had spiked to 44%.

Since 2012, billing has shifted from physician offices to hospital outpatient departments, especially in specialty practices. In chemotherapy administration, for example, physician offices saw almost 17% less volume between 2012 and 2018, while outpatient centers saw a 53% increase in volume, according to MedPAC.

Physicians in hospital-owned practices also refer more patients to the hospital’s facilities and, despite a common stumping point that integration improves quality through care coordination, its effect on quality is “ambiguous,” MedPAC analyst Dan Zabinski said Thursday at the committee’s November meeting.

Despite the mountain of evidence, the AHA published a widely-decried study in September claiming acquired hospitals see a reduction in operating expenses and a statistically significant drop in readmission and mortality rates. The study was criticized for not using actual claims data in its analysis among other methodological and conflict of interest concerns.

Republican leaders in the House Energy and Commerce Committee asked MedPAC to study provider consolidation in August, and the body’s full findings will be included in its March report to Congress.​






In a Boston acute care matchup, home beats the hospital

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Despite all of the recent hype, the idea of “hospital-at-home” is hardly a new concept. The first randomized, controlled study on the topic, published over 20 years ago, showed that the model was safe, finding that patients with five common conditions who would normally have been admitted to the hospital experienced similar outcomes when treated at home.

This week a new randomized, controlled trial from researchers at Boston-based Brigham and Women’s showed that hospital-at-home had better clinical outcomes and was a whopping 38 percent cheaper than equivalent management in an acute care hospital. Yes, the study was small (91 patients) and probably had some selection bias (just 37 percent of eligible patients chose home care).

Drilling into the data, length of stay for home-based patients was a little longer, but at-home patients received dramatically fewer lab tests, imaging studies and specialist consults—raising the question of whether all those daily chest x-rays, CBCs and curbside consults in traditional hospitals really provide value.

And 30-day readmissions and ED visit rates for home-based patients were less than half of the control group. Selection for clinical appropriateness and family support is critical, but experts estimate that up to a third of medical admissions could be managed in the home setting.

As growing evidence shows hospital-at-home to be safe, effective and lower cost, the lack of a reimbursement model to support investments in home-based acute care is now the greatest obstacle to widespread adoption.