Q&A: What States Can Learn from NASHP’s Hospital Cost Tool
Updated April 20, 2021/by NASHP Staff
What does “break-even” mean and include?
“Break-even” is an accounting term for the point at which revenues and expenses are equal. The break-even point can help purchasers of health care services determine the appropriate baseline that covers a hospital’s costs for providing patient services. As some purchasers may choose to consider additional costs when establishing their reimbursement rates (e.g., the costs of non-hospital health care facilities within the health system), NASHP’s tool presents three break-even point options. Each level, calculated as a percentage of Medicare rates, accounts for additional costs that are included in the hospital’s MCR.
- Reimbursing at Level 1 covers the cost of providing hospital patient services to commercially insured patients, plus any costs not covered by government programs, charity care, or uninsured patients.
- Reimbursing at Level 2 covers all Level 1 costs, plus all Medicare-allowed costs such as research, cafeteria expenses, and advertising. The tool excludes physician-direct patient costs because they are reimbursed separately from hospital reimbursements through other channels, such as fee schedules.
- Reimbursing at Level 3 covers all Level 1 and 2 costs, plus hospital non-operating income and expenses such as parking lot receipts and loss on investments.
Purchasers and hospitals may not agree on what level constitutes appropriate payment and may pursue a fifth baseline option offered by the tool: an average of Level 1 and Level 3.
How can information from NASHP’s Hospital Cost Tool be used to reduce health care spending?
Purchasers can use the tool to better determine what their baseline reimbursement to a hospital could be. Claims can then be run through a Medicare re-pricing tool to identify what is currently paid to each hospital as a percentage of Medicare. This information can aid purchaser negotiations with hospitals to achieve cost-based hospital reimbursement rates. The Montana State Employee Health Plan pursued this reference-based pricing to Medicare strategy and reduced its hospital reimbursements, increasing the plan’s reserves by $112 million within three years, allowing the plan to increase its sustainability without increasing premiums. Additionally, this data can be used to investigate costly drivers of hospital claims across hospitals, when adjusted for utilization. Hospital cost data can also inform state pursuit of cost-containment strategies, such as cost growth benchmarks, global hospital budgets, or public options.
Won’t lowering hospital reimbursements risk decreased access to care?
Every hospital selected by Montana for its new cost-based rates eventually agreed to the policy. Plan members ultimately kept full access to their network of providers. Before the one holdout hospital agreed to join the network at the new rates, the plan paid for members to receive care at a nearby in-network hospital free of copays and coinsurance, covering gas mileage and a hotel stay if needed. Nurse care managers also re-routed care as needed. As a result, members maintained access to care during this brief time period. Importantly, there were zero hospital closures as a result of the change, which maintained the community’s access to care.
Don’t commercial prices need to be so high because government programs underpay hospitals?
The RAND Corporation’s study, Nationwide Evaluation of Health Care Prices Paid by Private Health Plans, found no correlation between a hospital’s prices and the share of its case-mix-adjusted Medicaid and Medicare discharges.
If the question’s assumption was true, hospitals with higher prices would likely have had higher shares of Medicaid and Medicare patients – but that was not the case. NASHP’s Hospital Cost Tool allows purchasers to identify exactly what percentage of a hospital’s Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) costs are reimbursed. The tool also shows what percentage of a hospital’s total charges are attributable to each program, and a hospital’s profit margin for all government programs collectively. The tool’s breakeven levels calculate what the commercial rates as a reference to Medicare would be if commercial payers covered any potential shortfalls from public payers or the uninsured. The RAND study can further inform purchasers as it shows commercial prices at hospitals across the country.
Why address health care costs through hospital spending, particularly during a public health emergency?
Hospital spending is the largest health care expenditure in the United States. Combined with physician practices, which are increasingly being acquired by health care systems, hospital spending accounted for 53 percent of health care expenditures in 2018. According to the Health Care Cost Institute, the main drivers of rising health care spending are price increases, not increased utilization. At a time of diminished state budgets and profitable health care entities, addressing hospital prices presents the most significant potential to reduce health care costs. Analyzing hospital cost data through the tool’s could free up much-needed state revenue while still appropriately covering a hospital’s costs. For more information about health care costs, view the National Academy for State Health Policy’s Understanding the Health Care Cost Conundrum in 2020 slide deck.