Department of Pediatrics, Division of Hospital Medicine, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas, USA.
Children's Hospital Association, Lenexa, Kansas, USA.
J Hosp Med. 2024 Nov;19(11):1010-1018. doi: 10.1002/jhm.13423. Epub 2024 Jun 5.
There is a lack of uniformity across hospitals in applying inpatient versus observation status for short-stay (<48 h) pediatric hospitalizations, with negative financial implications associated with observation. Children with medical complexity (CMC) represent a growing population and incur high costs of care. The financial implications of inpatient and observation status for CMC have not been studied.
To compare costs and reimbursement for short-stay hospitalizations for CMC by inpatient and observation status, overall and stratified by payor.
We performed a cohort study of short-stay hospitalizations for CMC from 2016 to 2021 at 10 children's hospitals reporting reimbursement in the Pediatric Health Information System and Revenue Management Program. The primary outcome was the cost coverage ratio (CCR), defined as an encounter's reimbursement divided by the estimated cost.
There were 89,282 encounters included. The median costs per encounter were similar across observation ($5206, IQR $3604-$7484) and inpatient ($6547, IQR $4725-$9349) encounters. For government payors, the median CCR was 0.6 (IQR 0.2-0.9) for observation encounters and 1.2 (IQR 0.8-1.9) for inpatient. For nongovernment payors, the median CCR was 1.6 (IQR 1.3-1.9) for observation and 1.6 (IQR 1.4-2) for inpatient. Government reimbursement was associated with increased risk for financial loss (OR 13.91, 95% CI 7.23, 26.77) and with a median net loss of $985,952 (IQR $389,871-$1,700,041) per hospital annually for observation encounters.
Government-paid observation encounters for CMC are associated with significant financial loss at children's hospitals. This reimbursement model may pose a threat to children's hospitals' ability to care for CMC.
对于短期（<48 小时）儿科住院患者，不同医院在应用住院或观察状态方面缺乏一致性，而观察状态会带来负面的财务影响。患有复杂医疗状况（CMC）的儿童人数不断增加，且其医疗费用高昂。目前尚未研究 CMC 采用住院或观察状态的住院费用和报销情况。
比较 CMC 短期住院患者采用住院和观察状态的费用和报销情况，分别按支付方进行分层。
我们对 2016 年至 2021 年期间，在 10 家儿童医院进行的 CMC 短期住院患者进行了队列研究，这些医院在儿科健康信息系统和收入管理计划中报告了报销情况。主要结局指标为费用覆盖比（CCR），定义为某次就诊的报销金额除以估计费用。
共纳入 89282 例就诊。观察组（$5206，IQR $3604-$7484）和住院组（$6547，IQR $4725-$9349）的每次就诊费用中位数相似。对于政府支付方，观察组的 CCR 中位数为 0.6（IQR 0.2-0.9），住院组为 1.2（IQR 0.8-1.9）。对于非政府支付方，观察组的 CCR 中位数为 1.6（IQR 1.3-1.9），住院组为 1.6（IQR 1.4-2）。政府报销与财务损失风险增加相关（OR 13.91，95%CI 7.23，26.77），对于观察组，每家医院每年的净损失中位数为$985952（IQR $389871-$1700041）。
对于 CMC 患者，政府支付的观察性住院费用会给儿童医院带来重大财务损失。这种报销模式可能对儿童医院照顾 CMC 的能力构成威胁。
