An HMO Requests Your Hospital Services For Obstetrics

An Hmo Requests Your Hospital Services For Its Obstetrics Division It

An HMO requests your hospital services for its obstetrics division. It offers to pay your hospital $2,000 for a vaginal delivery without complications (DRG 373). You look at the Standard Test Procedure (STP) for this Diagnosis-Related Group (DRG) and discover that your hospital's cost is $2,400. What will you do to obtain the contract? Present your work as a 2-page report in a Word document formatted in APA style.

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Paper For Above instruction

In the competitive landscape of healthcare delivery, negotiations between hospitals and insurance providers such as Health Maintenance Organizations (HMOs) are critical to ensure financial viability while maintaining high-quality patient care. When an HMO requests hospital services for obstetrics and proposes a payment that falls below the hospital’s actual cost, the hospital must carefully analyze its operational costs, identify potential efficiencies, and strategize on ways to make such contracts profitable or at least sustainable. This report examines strategies to evaluate hospital costs related to obstetric procedures, explores operational data that can highlight cost reduction opportunities, calculates marginal profits under various scenarios, and proposes methods to negotiate contracts that reflect the hospital’s financial needs.

Analyzing Hospital Costs for Obstetric Procedures

To effectively respond to the HMO’s proposed payment, the hospital must first analyze its costs associated with vaginal deliveries classified under DRG 373. This involves reviewing the standard test procedure (STP), which provides benchmark costs adjusted for typical operative and non-operative elements. The hospital’s cost analysis should include direct costs such as personnel salaries, supplies, medications, and diagnostic tests, as well as indirect costs like overhead, administrative expenses, and equipment depreciation. A comprehensive cost accounting system, utilizing activity-based costing (ABC), enables precise allocation of costs to specific procedures, ensuring the hospital understands the true expense involved in each case.

Operational data—such as average length of stay, resource utilization per delivery, and staffing levels—are critical. For instance, by examining historical data, the hospital can identify fixed versus variable costs, enabling a more nuanced understanding of costs that can be adjusted. Moreover, this data can reveal inefficiencies, such as extended hospital stays or unnecessary diagnostic tests, that inflate costs without improving patient outcomes.

Identifying Cost Reduction Opportunities

Based on operational analysis, the hospital can identify several avenues for cost reduction. These may include streamlining nursing workflows to improve efficiency, negotiating bulk prices for supplies and medications, reducing unnecessary diagnostic testing, or implementing standardized clinical pathways to minimize variability and waste. For example, adopting clinical protocols that promote early ambulation and discharge criteria can decrease length of stay, thereby lowering per-case costs. Additionally, investing in staff training and process improvement initiatives, such as Lean or Six Sigma methodologies, can lead to significant efficiencies over time.

Calculating Marginal Profit Under Various Cost Profiles

With the current cost of $2,400 per vaginal delivery, accepting the HMO’s offer of $2,000 results in a direct loss of $400 per case, translating into a 20% deficit. To assess profitability under different scenarios, the hospital should model marginal profits based on potential cost reductions. For example, a 10% reduction in total costs (bringing the cost from $2,400 to $2,160) would still result in a loss of $160 per case at the offered rate. Conversely, if the hospital can reduce costs by 20% (to $1,920), accepting the $2,000 payment would yield a $80 profit per case. These calculations highlight the importance of targeted cost reductions and their impact on profitability.

Strategies to Make the Contract Profitable

To negotiate a financially sustainable contract, the hospital can employ several strategies:

  • Cost Negotiation: Present detailed cost data to the HMO, demonstrating the current shortfall, and propose a revised payment rate closer to the true cost, perhaps accompanied by performance incentives for quality outcomes.
  • Service Bundling and Volume Guarantees: Offer bundled services at a fixed price with a volume commitment, thus allowing for predictable revenues and economies of scale.
  • Improving Efficiency: Implement operational efficiencies, such as standardizing care pathways, reducing length of stay, and minimizing unnecessary procedures, thus lowering costs to meet the offered rate.
  • Quality Improvement and Value-Based Care: Incorporate metrics that incentivize quality, patient satisfaction, and safety, which may justify higher reimbursement rates and reduce liabilities related to complications or readmissions.
  • Share Savings Agreements: Negotiate contracts where the hospital shares in the savings achieved through efficiency gains, aligning incentives with the HMO.

By employing these strategies, the hospital can either accept the current rate and find ways to reduce costs or negotiate a higher rate that covers its expenses and yields a reasonable margin, ensuring financial sustainability without compromising care quality.

Conclusion

Addressing the challenge of a proposed payment below cost requires a comprehensive approach that combines detailed cost analysis, operational efficiencies, strategic negotiations, and value-based care initiatives. By thoroughly understanding its costs, identifying and implementing cost reductions, and engaging in transparent negotiations with the HMO, the hospital can develop a sustainable contractual agreement. Such efforts ensure that the hospital remains financially viable while continuing to provide high-quality obstetric care that meets patient needs and health system standards.

References

  • Baker, L. C., & Rozenshtein, A. (2018). Cost containment initiatives and obstetric care. Health Care Management Review, 43(2), 146-154.
  • Chernew, M. E., & Fendrick, A. M. (2020). Value-based insurance design. The New England Journal of Medicine, 382(22), 2087-2090.
  • Dranove, D., & Sanglier, M. (2017). Hospital cost accounting as a tool to improve financial performance. Medical Care Research and Review, 74(4), 411-426.
  • Fisher, E. S., & Staiger, D. O. (2019). Improving health care value: The importance of provider earnings and incentives. JAMA, 322(22), 2171-2172.
  • Ginsburg, P. B. (2011). Hospital responses to payment incentives: The case of readmission reductions. Health Affairs, 30(4), 632-638.
  • Gray, A., & Newby, C. (2019). Cost analysis in healthcare settings. Journal of Health Economics, 67, 45-60.
  • Kaiser Family Foundation. (2020). Trends in health system costs. KFF Health Reform. https://www.kff.org/health-costs/issue-brief/trends-in-health-system-costs/
  • Roberts, K., & Hsiao, W. (2021). The development and application of activity-based costing in hospitals. Healthcare Management Forum, 34(1), 13-19.
  • Thomas, S. (2019). Negotiating hospital contracts: Strategies for administrators. Journal of Healthcare Management, 64(4), 265-273.
  • Weinstein, J. N., & Stason, W. B. (2020). Cost-effectiveness of hospital-based obstetric care. Medical Decision Making, 40(3), 264-271.

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