Author(s): Andrew Tsang
Affiliation(s): Point B Consulting
Abstract
Background: Academic medical centers operate as financial paradoxes: the most essential community services systematically lose money while profitable elective procedures generate margins that subsidize unprofitable emergency care. This analysis examines profit margin patterns across 30 high-volume diagnosis-related groups (DRGs) to quantify cross-subsidization relationships within a representative academic medical center.
Objectives: To quantify profit margin variation across high-volume diagnosis-related groups (DRGs) in a representative large academic medical center, identify specific cross-subsidization relationships between profitable elective procedures and unprofitable essential/emergency services, and provide hospital leaders and policymakers with concrete data on the financial architecture that enables comprehensive care delivery.
Methods: DRG profitability patterns were analyzed using Medicare cost report data, calculating margins as the difference between Medicare payments and estimated costs for each diagnosis category. Service lines were categorized by clinical specialty and analyzed for volume-margin relationships.
Results: Orthopedic procedures generated positive margins averaging 22%, while critical care services demonstrated negative margins of 15% per case. Emergency conditions consistently showed negative margins requiring subsidization from elective procedures. Analysis reveals that profitable spinal fusion procedures generate sufficient margin to offset losses from approximately three sepsis cases.
Conclusions: Academic medical centers operate through cross-subsidization models where profitable elective procedures fund unprofitable emergency care. Understanding these dynamics proves essential as healthcare transitions toward value-based payment models and faces consolidation pressures that threaten comprehensive care delivery.
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