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What information is available in this section?

The top 50 Medicare inpatient procedures for the selected hospital

  • Average hospital charges
  • Average payments
  • Length of stay
  • Total number of patients

Top 50 Medicare outpatient procedures for the selected hospital

  • Average hospital charges
  • Average payments
  • Total number of patients

Medicare pricing information on specific inpatient procedures for all hospitals

  • Average hospital charges
  • Average payments
  • Total number of patients

Quality data on surgical infections and the most common causes of hospitalization

  • Heart attack
  • Congestive heart failure
  • Pneumonia

The inpatient and outpatient data excludes cases (or patients) that would have included an outlier payment. Outlier cases receive an additional payment over the diagnosis-related-group (DRG) or Ambulatory Payment Classification (APC) to offset higher than expected cost of care, as determined by the CMS Medicare Program. The inpatient data also excludes patients where the initial payment was from a payer other than Medicare.

Outpatient surgical procedures are excluded because the information available from the CMS does not include all of the charges, such as anesthesia, associated with each procedure.

The hospital charge for both inpatient and outpatient services exclude professional fees for any physician (surgeon, anesthesiologist, radiologist and pathologist) services.

The average Medicare payment includes the base payment, DRG for inpatient or APC for outpatient, and where applicable additional payments for graduate medical education, indirect medical education, disproportionate share, and capital in accordance with Medicare payment policies.

Medicare Advantage patients are not included in the patient count or in the calculations for charges and payments.

Critical access hospital (CAH) inpatient payment data is calculated using hospital-specific payment to charge ratios. CMS Medicare payment data for CAHs often are not reflective of the final payments CAHs receive for a specific procedure.

CAH outpatient procedures are representative of the charges and payments for that particular hospital for the most common outpatient procedures provided by smaller hospitals.

What can I learn from hospital quality information?

Hospital performance rates tell you the proportion of cases where a hospital provided the recommended process of care. Only patients meeting the inclusion criteria for a measure are included in the calculation of the rate for a measure. A rate of 88 percent means that the hospital provided the recommended process of care 88 percent of the time. The ultimate goal for all measures listed is 100 percent. Hospitals with effective quality improvement programs are continually working toward this goal. The quality information provided includes:

Measure: The name of the quality measure.

Number of Patients: The size of the data sample for the hospital quality measure.

Hospital Scores: The score that the hospital achieved for the quality measure. The score is expressed as a percentage of the sample size that was measured.

National Average: The average score achieved by all hospitals in the nation for the quality measure.

Michigan Average: The average score achieved by all hospitals in the state of Michigan for the quality measure.

How can Medicare information help me?

Medicare patients generally represent a significant portion of hospital patients. Medicare charges and payments can serve as a useful guide for consumers seeking information about specific services or procedures. The charges and payments for non-Medicare patients will vary depending upon the healthcare needs of each patient, whether or not the patient has insurance and whether the patient qualifies for a discount from hospital charges. The Medicare population is predominately elderly (65 and older) so there may be variations in service utilization which may impact the average charge and payments. For example, elderly patients often have complex medical conditions and multiple health issues that may result in a longer hospital stay and higher hospital charges.

Why do charges vary between hospitals for the same procedure or service?

There are many variables that impact hospital charges. These include:

Patient severity: Patients who are sicker or have multiple medical conditions generally require additional services, resulting in higher hospital charges.

Payer mix: Each hospital has a unique mix of payers. Government programs such as Medicare and Medicaid generally pay hospitals at rates less than the actual costs of providing care. Hospitals cannot remain financially viable if costs consistently exceed payments. As a result, hospitals that have a higher percentage of government-program patients must attempt to recover a greater percentage of their operational costs from privately insured and self-pay patients.

New technology: Hospitals with new technology may have higher charges than those with older equipment. The replacement cost for new equipment is typically higher than the original cost of the old equipment. In general, new technology improves patient care outcomes. In addition, it can result in patients receiving outpatient treatment rather than inpatient treatment which allows the patient to return home, recover and assume normal, daily activities sooner.

Labor costs: Salary and benefit costs vary by geographic region and are generally higher in urban areas. Shortages of nurses and other medical staff may increase hospital costs and impact hospital charges.

Range of services provided: Hospitals differ in the range of services provided to patients. Some provide a full range required for diagnosis and treatment, including very specialized services. Other hospitals may stabilize patients and then transfer them to another facility for specialized care.

Social mission: Hospitals provide services to ensure access to healthcare in their community even when they lose money on those services. Rural hospitals may have lower volumes for services critical to their community. Hospitals must attempt to recover these costs from privately insured and self-pay patients through higher charges. These services vary by community, but some examples include burn centers, trauma care, obstetrics, high risk nurseries, poison control centers, medical education, services for the poor, 24 hour and seven days a week availability, organ transplants and other programs.

Healthcare safety net: Hospitals provide services to all patients that access the emergency department regardless of their ability to pay. Some patients seek treatment at the hospital emergency department when they are unable to locate any other provider who accepts their insurance or if they lack insurance. Hospitals generally have charity care policies that provide assistance to patients in need that meet the requirements established by the hospital.

Why do payments vary between hospitals for the same procedure or service?

Medicare payments to hospitals vary depending on the Medicare payment policy based on the unique characteristics of the hospital.

Wage index: For both inpatient and outpatient, the national payment amount is adjusted by an area wage index to reflect regional variation in hospital salary and benefit rates. Generally hospitals located in urban areas tend to have a higher wage index.

Graduate medical education: Hospitals that have residency programs to train individuals after completion of medical school receive additional payments from Medicare. These payments provide a partial offset to the hospital costs for training these future physicians (salaries and benefits for residents, faculty teaching stipends, administrative cost to operate the residency programs). Hospital residents provide services to all patients, not just Medicare patients. These payments are crucial for ensuring that patients in the future have an adequate supply of physicians to meet their medical needs.

Indirect medical education: Medicare provides payments to teaching hospitals to reimburse the additional indirect costs of patient care associated with operating an approved teaching program. These costs include tests utilized to diagnose and treat patients.

Disproportionate share: Hospitals that treat a large number of low-income patients receive additional Medicare payments to offset some of the losses incurred in treating these patients. Low-income patients tend to be sicker and more costly to treat than other patients with the same diagnosis. Higher costs also result from the need for additional staffing and services, such as translators and social workers, to care for low-income patients.

Critical access hospitals: Hospitals with fewer than 25 beds may be classified as critical access by Medicare. These hospitals are reimbursed at 101 percent of cost allowable by Medicare, which is lower than the full cost of providing care. This Medicare payment method recognizes the unique challenges CAHs face in providing healthcare services in rural areas. This special designation helps provide access to healthcare for all patients in rural areas.

Why is there a difference between what hospitals charge and the payments they receive?

Federal regulations require a hospital to charge all its patients the same amount (with limited exceptions) for the same service. The amount collected by the hospital is almost always less than the amount billed for three main reasons:

  • Government programs, such as Medicare and Medicaid, typically pay hospitals much less than the billed charge. These payments are determined by government agencies and hospitals do not have any ability to negotiate these rates.
  • Insurance companies negotiate discounts with hospitals on behalf of the patients they represent.
  • Hospitals typically have policies that allow low-income persons to receive reduced-charge or free care.

What is the data source for the hospital quality information?

The quality data is based on information from Hospital Compare, a public website created by the CMS along with the Hospital Quality Alliance (HQA). The HQA is a public-private collaboration established to promote reporting on hospital quality of care. The HQA consists of organizations that represent consumers, hospitals, physicians, nurses, employers, accrediting organizations and federal agencies. Hospital Compare displays rates for process of care measures that show how often hospitals provide the care that is recommended for patients being treated for a heart attack, heart failure, pneumonia, or patients having surgery. Hospitals voluntarily submit medical data for all of their adult patients for these measures.

CMS does not require CAHs to report these process measures; however some Michigan CAHs voluntarily report their data to CMS and other CAHs voluntarily submit their data directly to the MHA.

Why do some hospitals show partial or no data for the quality and price information?

Hospitals that specialize in a particular type of care (i.e., psychiatric, long-term acute care, rehabilitation) do not provide all of the most common services. Some smaller hospitals (i.e., rural and critical access hospitals that have less than 25 beds) may only perform a few of the most common services.

Some hospitals do not provide care to a minimum number of Medicare patients to allow the display of their data. The CMS requires that for any inpatient or outpatient procedure a minimum of 11 Medicare patients must exist before data can be displayed.

May 13, 2015
CAUTI Regional Learning Session and Safe Table
This learning session and Safe Table will be held from 8:30 a.m. to 3:00 p.m. at the Radisson Hotel, Kalamazoo. Topics will include nurse-driven protocols and patient and family engagement, teamwork and antimicrobial stewardship. Register online or contact Michelle Norcross for assistance.
May 14, 2015
CUSP Implementation Workshop
This one-day workshop will be held from 8:00 a.m. to 4:00 p.m. at Shanty Creek Resort, Bellaire. Led by Johns Hopkins CUSP experts, learners will work in groups to devise solutions to common barriers, develop an understanding of the roles of different CUSP team members and learn from others’ experiences. Before attending the workshop, participants must complete nine online Foundations of CUSP modules. Register online or contact Tammy Nault for assistance.
May 28, 2015
MHA Keystone: Pain Management Workshop
This workshop will be held from 8:00 a.m. to 4:00 p.m. May 28 at the Dearborn Inn. Hospital teams will hear from experts on the implementation and spread of quality improvement work, common challenges in treating chronic pain patients, patient and family engagement, patient-controlled analgesia, emergency department opioid prescribing practices and opioid safety in the inpatient setting. Register online or contact Tammy Nault for assistance.
  • Annual Symposium

    Annual Symposium

    The MHA Patient Safety & Quality Symposium offers an opportunity to explore innovative patient safety techniques and dialogue with others about how to enhance patient safety across the continuum. Learn new strategies and ideas from faculty who are game-changes in the healthcare and business world.

  • Patient and Family Engagement

    Patient and Family Engagement

    Michigan hospitals and the MHA Keystone Center are committed to including patients and families in improving care and focusing improvement efforts with a patient-centric approach. To that end, the MHA Keystone Center is a proud Pinwheel Sponsor of the Institute for Patient- and Family-Centered Care.

  • Pain Management

    In May, the MHA Keystone Center is launching MHA Keystone: Pain Management to implement evidence-based best practices around pain control and to help patients better manage their pain in the hospital. Contact Michelle Norcross to learn more.