Abstract 14967: The Adverse Economic Impact of Inpatient Hospitalization for Evaluation of Patients with Unexplained Syncope

Abstract

Background: Syncope often prompts an ER visit and subsequent hospitalization. Hospital reimbursement for Medicare pts with syncope is based on a DRG; increasingly, payment is being denied because pts did not meet criteria for admission. Typically these are low risk pts who despite undergoing multiple tests over several days are ultimately discharged with no diagnosis or a diagnosis of vasovagal syncope. The aims of this study were (1) to assess the frequency with which our hospital was denied reimbursement and (2) to assess the economic impact when caring for these pts.

Methods: We determined the frequency of reimbursement denials under a Medicare RAC audit initiative evaluating pts discharged between 2008-2009. We then identified a cohort of Medicare pts who presented to our ER in 2011 with syncope (ICD-9: 780.2) and were discharged with DRG 312 (syncope and collapse). We collected data on whether pts were hospitalized in an observation status or as inpatients and the difference between the cost of delivering care and reimbursement.

Results: During the RAC audit period, DRG 312 was the most common reason for denial of reimbursement (accounting for 20% of all denials), primarily on the grounds that pts did not meet criteria for admission. In 2011, 579 Medicare pts presented to our ER with syncope. Of these, 396 (68%) pts were hospitalized, either in an observation status (n=71 [18%]) or as inpatients (n=325 [82%]). The 325 inpatients, 56% of the total cohort, accounted for 86% of the total costs spent on patients with syncope. The care of each inpatient resulted in an ~$1800 deficit to the hospital, before taking into account future formal denials of reimbursement.

Conclusions: Recent guidelines suggest that pts with syncope should undergo early risk stratification (possibly through use of observation units) and that hospital admission be reserved for high-risk pts. Our data show the economics also support such an approach. Under current Medicare reimbursement trends, continued inpatient hospitalization of low risk pts with unexplained syncope will result in large economic losses to hospitals. There is thus a desperate need to better risk stratify syncope admissions and to refine work-ups to be more cost-efficient.