Reducing Hospital Utilization and Related Expenses at the Community Level

The reduction of health care expenses continues to be a major challenge for the economy and society of the United States and other nations. This study focused on a major source of health care expenses, inpatient hospitals, at the community level. It was based on the assumption that fewer inpatient hospital admissions per population contribute to lower health care costs. The study demonstrated that the hospitals of Syracuse, New York have generated fewer inpatient admissions and discharges than those of other New York State metropolitan areas per population. It suggested that the application of utilization rates for inpatient hospitalization in Syracuse to some other New York State areas could result in substantial savings. Between 2016 and 2017, the hospital discharge rates in Syracuse were 1.6 3.1 percentage points lower than those of Albany, 2.2 5.0 percentage points lower than those of Rochester, 4.1 4.9 lower than those of New York City, 5.4 8.2 percentage points lower than those of Buffalo, and 17.2 18.3 percentage points lower than those of Utica. The study suggested that the conservative hospitalization rates in Syracuse were developed and sustained over long periods of time through the use of ambulatory surgery, reduction of admissions through hospital emergency departments, and limitation of the inpatient bed supply. This was a lengthy process that resulted in a conservative hospital admission pattern. The study demonstrated, more recently, that specific programs such as the reduction of inpatient hospital readmissions and hospital lengths of stay have supported additional reductions of hospital and related utilization in Syracuse.


Introduction
In the United States, the importance of health care expenses with respect to the How to cite this paper: Lagoe, R. and Littau, S. (2018) Reducing Hospital Utilization and Related Expenses at the Community Level. Case Reports in Clinical Medicine, 7, 541-549. economy and society continues to increase. Health care providers and payers have become a larger part of the economy. At the same time, their expenses have become an increasing burden for government, businesses, and consumers [1] [2]. In New York State, these organizations dominate the list of the largest employers [3].
Health care expenses have become major challenges for federal and state budgets through the Medicare and Medicaid programs. They are also reducing the ability of American industries to compete in international markets [4].
Per capita health care expenses in the United States are 29 percent higher than those of the next nation. At the personal level, these expenses are limiting the ability of American families to pay costs of living [5].
It has been demonstrated that much of the increased costs of health care in the United States is related to variations in hospital use. Increases in hospital admission rates have produced excess costs at the community level [6] [7] [8] [9].
At the national and community levels, different approaches have been employed to limit health care expenses. Major employers, such as Amazon, are showing greater interest in providing health care services themselves in order to limit costs. Initiatives by major payors such as Medicare, Medicaid, and private insurance plans are also addressing reduction of health care expenses for hospital and other services [10] [11] [12].
Programs for Medicare, such as MACRA; Medicaid, such as DSRIP; and insurance companies, such as ACQA, have involved reduction of hospital admissions through substitution of other services, such as nursing home admissions, home health care visits, ambulatory care, and other community services for hospital care [13].
The impact of these developments has been reflected at the community level.
Health care providers such as hospitals and physicians have become major employers. Local governments and businesses have been responsible for paying the expenses of care.

Population
This study focused on hospital discharges and related health care expenses in the These hospitals provide a full range of services to an immediate service area of about 600,000. They also provide tertiary services to the eleven county Central New York Health Service area with a population of approximately 1,400,000.
Historically, the Syracuse hospitals have worked cooperatively to improve the efficiency and outcomes of health care in their service area. These efforts have included programs to limit inpatient admissions with other local providers and programs to reduce hospital lengths of stay with area nursing homes and home

Method
This study focused on hospital admission/discharge rates as an indicator of health care expenses in the metropolitan area of Syracuse, New York. Hospital admission/discharge rates were used to evaluate these expenses because they include some of the highest health care expenses. Reduction of hospital use rates has been an objective of many efforts to limit health care expenses.
Health care expenses, rather than health care costs, related to utilization were evaluated in the study. Actual health care costs for the New York State metropolitan areas were not available.
The study focused on health care utilization and expenses, rather than outcomes. Hospital readmissions were summarized in the second component of the study. Data concerning hospital complications and readmissions were summarized in the following articles [16] [17] [18] [19].
The study also focused on utilization and expenses, rather than mortality and patient satisfaction. Updated population data concerning hospital mortality were not available for the metropolitan areas evaluated. Patient satisfaction information for specific health services was also not available for these popula- The differences in rates between Syracuse and the other areas were used to estimate the contributions of hospital admission/discharge rates to these costs during this period. It was assumed that these differences were generated, in part, by differences in utilization of inpatient hospital services.

Results
The initial component of the study concerned hospital admission/discharge rates per population for major acute care services, including adult medicine, adult surgery, pediatrics, and obstetrics in the metropolitan area of Syracuse, New York. Related data are summarized in Table 1.
This information demonstrated that the Syracuse hospitals generated conservative hospital utilization rates, especially during the most recent years of the period, 2016 and 2017. During these years, the hospital discharge rates in Syracuse were 1.6 -3.1 percentage points lower than those of Albany, 2.   Table 2. The third component of the study involved length of stay reduction in the Syracuse hospitals. Relevant data are summarized in Table 3.
Historically, the Syracuse hospitals have implemented programs with local nursing homes that have reduced lengths of stay by substituting long term care

Discussion
The reduction of health care expenses continues to be a major challenge for the economy and society of the United States and other nations. These expenses are a substantial burden for government, businesses, and individuals. The health care system of the nation is a major employer. At the same time, it is also the source of large expenses at the national, state and local levels.
One approach to reducing health care expenses or limiting their growth involves the utilization of services at the community level. Inevitably, this process concerns health care providers.
This study addressed the utilization of health care for a major source of health care expenses, inpatient hospitals, at the community level. It was based on the assumption that fewer inpatient hospital admissions per population contribute to lower health care costs.
The study demonstrated that the hospitals of Syracuse, New York, over time, have generated fewer inpatient admissions and discharges than those of other New York State metropolitan areas per population. It suggested that the application of utilization rates for inpatient hospitalization in Syracuse to some other New York State areas could result in substantial savings.
The study suggested that the conservative hospitalization rates in Syracuse were developed and sustained over long periods of time through the use of ambulatory surgery, reduction of admissions through hospital emergency departments, and limitation of the inpatient bed supply. This was a lengthy process that resulted in a conservative hospital admission pattern.

Case Reports in Clinical Medicine
The study demonstrated that, more recently, specific programs such as the reduction of inpatient hospital readmissions and hospital lengths of stay have supported additional reductions of hospital and related utilization in Syracuse.
These efforts have been implemented by the area hospitals individually and collectively.
This information suggests the need for incremental efforts to address health care expenses at the community level. These efforts will require the creativity and participation of providers and the populations that they serve.