MEDICA@MUSC (Medical University of South Carolina)
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Hospital Uncompensated Care Costs and Profits: A Comparison of Mississippi and Arkansas, Pre- and Post- Medicaid Expansion
Get PDFResearch Objective
Mississippi\u27s healthcare systems are ranked 49 out of 50 on many overall performance indicators, including access to care, quality of care, cost and utilization of services, health outcomes, and income-based healthcare disparities. Nationally, some evidence suggests coverage gaps are wider and growing faster in states that have yet to adopt Medicaid expansion. Multiple hospitals across Mississippi are currently experiencing financial instability, which could cause service reductions or closures, particularly in rural (54%) areas such as the Mississippi Delta. Because of these performance constraints, we evaluated Mississippi hospital uncompensated care costs, total margins, and operating margins for years 2011-2020. We then compared those outcomes to Arkansas, a state that expanded Medicaid in 2014, which is geographically contiguous to Mississippi and similar in many respects (demographics, population, rurality, etc.,). The objective of this study was to describe and compare changes in Mississippi hospitals’ financial performance to Arkansas hospitals’ performance, pre- and post- Medicaid Expansion.
Study Design
This research is a quantitative research design that provided descriptive statistics on Mississippi hospitals compared to hospitals in Arkansas, a state that adopted ACA Medicaid Expansion early on January 1, 2014, using a descriptive difference-in-differences approach. This approach compared two differences, the treatment group – the state of Arkansas, and the control group – the state of Mississippi. The data includes years 2011-2013 for pre-expansion and 2015-2020 for post-expansion. Key outcomes of this evaluation include uncompensated care costs, operating margins, and total margins in Mississippi Hospitals. The primary data source is Healthcare Cost Reporting Information System (HCRIS) Cost Reports between 2011-2020.
Population Studies
We evaluated all hospitals in Mississippi and Arkansas that reported Healthcare Cost Reporting Information System (HCRIS) Cost Reports in 2011-2020.
Principal Findings
When compared to Mississippi in the pre-expansion period, Arkansas had slightly more uncompensated care costs. Post Medicaid Expansion, uncompensated care cost percentages declined for hospitals in Arkansas and stayed down compared to hospitals in Mississippi, where we saw a slight increase. When compared to Mississippi in the pre-expansion period, Arkansas reported more bad debt. Post Medicaid Expansion, the amount of bad debt incurred by hospitals declined constantly in Arkansas, compared to hospitals in Mississippi, where we saw an increase, then a slight decrease to where Arkansas was at expansion in 2014. In evaluating total and operating margins pre-expansion, Mississippi performed better; however, post-expansion Mississippi always performed worse financially. Post-expansion, Arkansas improved profit margin. Due to the COVID-19 pandemic and government relief funding, results varied in 2019 and 2020. Overall, our results show that all four measures (uncompensated care costs, bad debt, total margins, and operating margins) improved significantly in Arkansas post-Medicaid Expansion compared to Mississippi.
Conclusions
Mississippi performed better on all measures pre-2014 and performed worse on all measures post- 2014. Overall, our results show that all four measures (uncompensated care costs, bad debt, total margins, and operating margins) improved significantly in Arkansas post-Medicaid Expansion compared to Mississippi.
Implications for Policy or Practice
Ultimately, not choosing to expand Medicaid could potentially lead to financial constraints and solvency concerns among hospitals in those states. Our findings may inform policymakers in non-expansion states balancing concerns about the effect of Medicaid expansion on state budgets with concerns about the impact on hospital performance
Factors Affecting the Healthcare of Adults with Communication Difficulties due to Autism Spectrum Disorder and/or Intellectual and Developmental Disability
Get PDFPurpose: This dissertation explores the healthcare barriers and facilitators experienced by autistic adults and adults with intellectual and developmental disabilities (IDD) who have communication difficulties (CD).
Problem: Approximately 5-10% of Americans have CD, including difficulties such as stuttering, aphasia, apraxia, and other forms of language impairment(1,2). Communication difficulties are present in about 25-30% of autistic individuals and 57.9% of those with IDD, which accounts for a large and poorly studied portion of those with CD(3,4). Individuals with CD report negative healthcare experiences and decreased levels of satisfaction with healthcare providers secondary to practices such as communication solely with a patient’s supporter that disregards the patient, and/or failing to accommodate a patient’s need for alternative and augmentative communication (AAC)(5–9). This decreased satisfaction and more frequent experience of negative healthcare interactions leads to poorer perceptions of healthcare(?), less frequent use and access to primary care services, and increased use of emergency departments for non-emergent situations(5,7,8,10–13). Healthcare providers, particularly those caring for adults, similarly note an inability to accommodate AAC needs of patients with CD, as well as a lack of knowledge about these disorders(5,13,14).
Objective: The overall objective of this dissertation was to investigate and develop a better understanding of the factors influencing healthcare access and effective communication in the inpatient healthcare setting for adults with IDDs/CDs. The specific aims were: Aim 1: To analyze and synthesize current knowledge about the barriers to and facilitators of access to care in adults with IDDs/CDs through the lens of Levesque et al.’s conceptual framework of access to healthcare(15). Aim 2: To examine and appraise the research literature on interventions designed to improve health communication for patients with IDDs/CDs through the lens of the FR2A4ME2 framework(13). Aim 3: To gain insight into providers’ experiences, needs, and perspectives regarding caring for the adult IDD/CD population. Aim 3a. To measure hospital providers’ perceptions of self-efficacy (SE) using the Provider Self-Efficacy Scale for Communicating with Adults with CDs (PSESCACD) instrument through on online survey. Aim 3b. To explore, through qualitative interviews, the actual and perceived barriers to and facilitators of implementing elements of the FR2A4ME2 model of communication in providing care for adult patients with CDs through the lens of the Social Ecological Model.
Design: An integrative review was conducted to evaluate current knowledge of the barriers to and facilitators of healthcare access in adults with IDD and CD using Levesque et al.’s conceptual framework of access to care (Aim 1). Findings from this review informed the framework and design of the dissertation study. A scoping review of current healthcare interventions for patients with CD was conducted (Aim 2). A multiple methods design was used for the dissertation study (Aim 3), informed by the Social Ecological Model (SEM) and the FR2A4ME2 framework which were applied to analyze the barriers and facilitators to care as identified by in-hospital healthcare providers(13,16,17). The Provider Self Efficacy Scale on Caring for Adults with Communication Disorders (PSESCACD) was administered through an online survey to measure provider reported SE as well as providers’ perceptions of SE in using specific communication strategies when communicating with adult patients with CD. Methods of qualitative description informed the conduct and analysis of key informant interviews with providers to gain insight to their perceptions of factor influencing effective communication(18).
Results: A multitude of barriers and facilitators to healthcare access were identified using Levesque et al.’s framework(15). Ineffective communication was found to be a substantial barrier to care for adults with IDD and/or ASD, as well as previous negative healthcare experiences, lack of provider training and competency, and a tendency of providers to rely on supporters. Current inpatient healthcare interventions were found to focus specifically on adults with acquired CD, with the greatest impact on improving knowledge, skills, and the ability of healthcare providers to utilize some elements of the FR2A4ME2 framework with patients and supporters.
The findings of the 19 provider interviews reflected and amplified the barriers and facilitators to healthcare access identified in manuscripts one and two. Both the integrative and scoping reviews noted a lack of education among adult healthcare providers, as well as a lack of available alternative communication resources, and both were noted as barriers by healthcare providers from various health systems of varying types of institutions in the dissertation study.
While inpatient interventions focused on addressing some of these barriers, such as lack of staff knowledge and education, barriers such as a lack of resources remain predominantly unaddressed.
Conclusions: Findings from this dissertation can be used to guide the development of future studies on interventions for adults with non-acquired CD, a new model to guide communication of healthcare providers with individuals with CD, and changes within organizations related to resource availability, current systems of care, and continuing education. They underscore the need for further intervention development and implementation studies with this patient population. While the findings of the study are congruent with current literature, they expand upon them by exploring the interplay of factors across the SEM and impact of use of elements of the FR2A4ME2 framework
A Quality Improvement Initiative to Improve Follow-up Time and Reduce Readmissions and Emergency Department Utilization for Oncology Patients
Get PDFHospitals across the nation are facing extreme challenges with overcrowding. Unplanned readmissions and emergency department use are two significant contributors to this urgent issue. Historically, oncology patients are high utilizers of emergency department services, and have elevated numbers of unplanned readmissions. This is especially true of gastrointestinal medical oncology patients. In an effort to move the needle in the right direction, an operational quality improvement initiative to decrease emergency department utilization and unplanned readmissions was conducted. This pilot project took place over a three-month period, and consisted of protecting time for advanced practice providers (APPs) and updating inefficient workflows. The primary goal was to reduce the number of days between discharge from the inpatient setting, and days to first follow up appointment in the outpatient setting. A secondary goal was to reduce readmissions and emergency department (ED) utilization. Results showed that to improve transitions of care, implementation of a Donabedian modeled APP structural change, in combination with optimizing workflow, can reduce the length of time between 4 discharge from the inpatient (IP) setting to first follow up appointment. This change in return shows a correlation with a reduction in readmission rates and ED department utilization
The Role of Complement in Stroke and Traumatic Brain Injury
Get PDFBrain and neural injury are a non-specific disease category that includes traumatic brain injury (TBI) and stroke. Both TBI and stroke are common, costly, and leading causes of severe disability in adults. Both stroke and TBI are responsible for substantial disability in working age adults, with stroke being the second leading cause of death worldwide [1] and TBI a major cause of disability in people younger than their 40\u27s [2]. The immune response after brain injury is multifactorial and involves both local and systemic events at the cellular and molecular level. The complement system is a component of both the innate and adaptive immune response and can be activated via one of three pathways: the classical, lectin, or alternative pathway. Studies by our lab and by others have established a prominent role for complement in propagating secondary injury after ischemic or traumatic insult to the brain [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. The complement system is recognized as an early and significant contributor to secondary insult after TBI by promoting neuronal loss, edema, and inflammatory cell infiltrate [14]. Clinical studies have shown that TBI patients have elevated levels of complement activation products (C3 and sC5b-9) in their cerebrospinal fluid and increased deposition of complement activation products in the perilesional brain [7], [15], [16], [17], [18]. The source of complement deposited after a TBI is a combined contribution of systemic complement, leaking to the brain after trauma-induced blood brain barrier dysfunction, and locally produced complement proteins by the brain parenchyma and infiltrating cells [7], [16], [17], [19]. A similar pattern of complement deposition is seen in experimental models of TBI that also implicate complement in the acute neuronal cell death, neutrophil extravasation, and worsening of outcomes after TBI [9], [10], [11], [12], [13], [20], [21], [22], [23], [24], [25]. 4 Complement is also a major mediator of acute pathology after stroke, and previous work from our lab and others have shown that complement serves as the recognition arm of the immune system to detect and respond to cellular stress in the penumbra leading to a robust neuroinflammatory response [26]. In addition, preclinical and clinical studies have shown significant complement activation in the ischemic penumbra, and elevated serum complement is associated with stroke outcomes [26]. We have also shown that complement increases acute neuronal loss, increases distal thrombosis, and promotes a chronic neuroinflammatory response after stroke leading to worsening of acute and chronic outcomes [14], [26]. A challenge in designing medical treatments for TBI and stroke is the location and multifactorial nature of the pathologies, which are complex and involve dysfunction of multiple homeostatic processes. Studies in animal models have greatly enhanced our understanding of the complex pathophysiology that underlies stroke and TBI and has enabled screening of over 1,000 novel therapeutic agents. A major concern in translational stroke research is that therapeutics that are deemed efficacious at the rodent level fail to show efficacy when moved to clinical trials. Reasons for failure of prior therapies include lack of assessment of chronic outcomes, lack of gender consideration, exclusion of age and other co-morbidities, administering therapeutics at time points not clinically relevant, failure to assess risk profile of novel therapies, and lack of significant motor and cognitive behavioral assessment. While it has long been recognized that neuroinflammation is injurious and represents a therapeutic reparative target, only more recently has it been recognized that neuroinflammation can also contribute to homeostatic and reparative mechanisms after brain injury. Consequently, an emerging paradigm is that systemic and complete 5 inhibition of neuroinflammation after brain injury is unlikely to be an optimal approach, and that localized and targeted inhibitory strategies, possibly of limited duration, will provide a better therapeutic approach. The goal of treatment has transitioned from symptomatic management to approaches for neuroprotection and regeneration [27]. The complement system is being discussed as a therapeutic target for TBI as well as stroke, due to data supporting a pivotal role for complement in supporting several downstream activities that promote neuroinflammation and degeneration [27]. An extensive understanding of the acute, subacute, and chronic consequences of complement activation is needed in both stroke and TBI and may lead to new therapeutic strategies, including the ability of targeting selective steps in the complement cascade