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
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.
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.
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...
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).
also thanks @LorenAdler @michaelannica @allanmjoseph @jp_mcginnis who explained payment and clinical issues to me!
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