with the explosion in #COVID19 cases in NYC and around the country, you may be wondering what hospitals will be paid to treat these patients. in this thread i& #39;ll walk through how that& #39;s going to work.
i& #39;ll assume the hospital bills medicare: half of #COVID19 patients are 65+, other insurers often use the same or similar payment approaches, & hospitals might get medicare rates for uninsured patients under the CARES act. i& #39;ll account for the 20% payment bump in the CARES act too
i& #39;ll show prices for @nyphospital. to simplify things i assume:
1) the patient has a principal diagnosis–the underlying reason for their admission–of #COVID19
2) it& #39;s April 1 or later (no COVID-specific diagnosis code before then)
3) they don& #39;t have HIV & they aren& #39;t a newborn
1) the patient has a principal diagnosis–the underlying reason for their admission–of #COVID19
2) it& #39;s April 1 or later (no COVID-specific diagnosis code before then)
3) they don& #39;t have HIV & they aren& #39;t a newborn
if the patient gets no big procedures, by emergency @CMSGov rule they& #39;ll be classified "respiratory infections and inflammations" patients. for those in the know, that& #39;s diagnosis-related groups (DRGs) 177-179. @nyphospital payment ranges from $13K-$25K. let& #39;s narrow that down.
the payment for a respiratory infections & inflammations patient depends on whether they had a complication or comorbidity (called a CC). these are determined from other diagnoses on the bill.
no CC? $12K.
a CC (like chronic heart failure)? $17K.
a major CC (like sepsis)? $25k.
no CC? $12K.
a CC (like chronic heart failure)? $17K.
a major CC (like sepsis)? $25k.
on the other hand, about one-sixth of #COVID19 patients go to the intensive care unit, where they might go on a ventilator. if so, hospitals receive *much* higher payment. if the patient gets under 4 days of ventilator support it& #39;s $33K. if 4+ days of ventilator support, $74K.
patients on the ventilator long-term might get a tracheostomy. the hospital would be paid twice as much for that case: $148K.
very rarely, a #COVID19 patient could get ECMO, an incredible procedure that bypasses the heart & lungs: $242K, the 3rd highest payment DRG in Medicare.
very rarely, a #COVID19 patient could get ECMO, an incredible procedure that bypasses the heart & lungs: $242K, the 3rd highest payment DRG in Medicare.
these numbers aren& #39;t the last word. if a patient is very costly, hospitals get outlier payments for 80% of the costs beyond the medicare payment + a loss threshold (~$33K for @nyphospital). costs=charges on the bill deflated by a markup factor (called the cost-to-charge ratio).
these are all payment rates for @nyphospital. other hospitals might get paid more or less. each $ value i presented was (mostly) produced by multiplying a DRG "weight" (a standardized price) by area- and hospital-specific conversion factors. more info: http://www.medpac.gov/docs/default-source/payment-basics/medpac_payment_basics_16_hospital_final.pdf">https://www.medpac.gov/docs/defa...
now for the receipts.
half of #COVID19 patients 65+ https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html">https://gis.cdc.gov/grasp/COV... & https://www.kff.org/other/state-indicator/distribution-by-age/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
other">https://www.kff.org/other/sta... insurers pay like medicare: @zackcooperYale @stuartcraig @MartinSGaynor @johnvanreenen https://healthcarepricingproject.org/sites/default/files/Updated_the_price_aint_right_qje.pdf
CARES">https://healthcarepricingproject.org/sites/def... act to pay Medicare rates: https://www.nytimes.com/2020/04/03/upshot/trump-hospitals-coronavirus.html">https://www.nytimes.com/2020/04/0...
half of #COVID19 patients 65+ https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html">https://gis.cdc.gov/grasp/COV... & https://www.kff.org/other/state-indicator/distribution-by-age/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
other">https://www.kff.org/other/sta... insurers pay like medicare: @zackcooperYale @stuartcraig @MartinSGaynor @johnvanreenen https://healthcarepricingproject.org/sites/default/files/Updated_the_price_aint_right_qje.pdf
CARES">https://healthcarepricingproject.org/sites/def... act to pay Medicare rates: https://www.nytimes.com/2020/04/03/upshot/trump-hospitals-coronavirus.html">https://www.nytimes.com/2020/04/0...
receipts 2:
20% payment bump: https://www.aha.org/special-bulletin/2020-03-26-senate-passes-coronavirus-aid-relief-and-economic-security-cares-act
DRG">https://www.aha.org/special-b... rules for #COVID19 diagnoses: https://edit.cms.gov/files/document/icd-10-ms-drgs-version-371-r1-effective-april-1-2020-updated-march-23-2020.pdf">https://edit.cms.gov/files/doc... & https://www.cms.gov/icd10m/version38-fullcode-cms/fullcode_cms/P0001.html
https://www.cms.gov/icd10m/ve... href="https://twitter.com/ahahospitals">@ahahospitals coding guidelines: https://www.aha.org/fact-sheets/2020-03-30-frequently-asked-questions-regarding-icd-10-cm-coding-covid-19
17%">https://www.aha.org/fact-shee... of #COVID19 inpatients to ICU: https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e2.htm">https://www.cdc.gov/mmwr/volu...
20% payment bump: https://www.aha.org/special-bulletin/2020-03-26-senate-passes-coronavirus-aid-relief-and-economic-security-cares-act
DRG">https://www.aha.org/special-b... rules for #COVID19 diagnoses: https://edit.cms.gov/files/document/icd-10-ms-drgs-version-371-r1-effective-april-1-2020-updated-march-23-2020.pdf">https://edit.cms.gov/files/doc... & https://www.cms.gov/icd10m/version38-fullcode-cms/fullcode_cms/P0001.html
https://www.cms.gov/icd10m/ve... href="https://twitter.com/ahahospitals">@ahahospitals coding guidelines: https://www.aha.org/fact-sheets/2020-03-30-frequently-asked-questions-regarding-icd-10-cm-coding-covid-19
17%">https://www.aha.org/fact-shee... of #COVID19 inpatients to ICU: https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e2.htm">https://www.cdc.gov/mmwr/volu...
payment calculation:
i used @CMSGov PC Pricer software with provider number 330101 ( @nyphospital): https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/inpatient
i">https://www.cms.gov/Medicare/... assume patient has the average length of stay for their DRG. to reflect the CARES bump i add 20% to the payment (excluding the per diem & per stay parts).
i used @CMSGov PC Pricer software with provider number 330101 ( @nyphospital): https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/inpatient
i">https://www.cms.gov/Medicare/... assume patient has the average length of stay for their DRG. to reflect the CARES bump i add 20% to the payment (excluding the per diem & per stay parts).
also thanks @LorenAdler @michaelannica @allanmjoseph @jp_mcginnis who explained payment and clinical issues to me!