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Biomedical subjects

R Feldman

Publications and source records attributed to R Feldman.

At least 37 records · Page 2Linked to original sources
PubMed1997

How do states buy health insurance for their own employees?

State governments play many roles in local health insurance markets. This paper focuses on the role of states as employers. As managed care and health care costs continue to grow, state governments engage in a variety of health insurance purchasing practices that influence the structure of health benefits offered to state employees. Descriptive analysis shows that many states have adopted managed competition to some degree, as well as traditional cost-reducing measures such as utilization review and self insurance. The experience of state governments can provide a benchmark for other public and private employers.

Cost Control↗
PubMed1997

[Correlation of carbamazepine levels in blood with clinical poisoning states, evaluated with the help of the APACHE II system and the Matthew coma scale].

Acute carbamazepine (CBZ) poisoning occurs recently quite often. Symptomatology of poisoning is variable but usually various degrees of consciousness impairment prevail. 77 patients (36 women and 41 man, mean age 31.5) were hospitalized last two years in this Centre. Clinical condition was evaluated in a regular descriptive way, classifying the degree of coma according to the Matthew scale but also by calculating the scores according to APACHE II and TOXSCORE. Serum CBZ was measured. A slight falling trend was found of the relation of the serum CBZ in the range 6-37.8 micrograms/ml (38 micrograms/ml = median) to APACHE II score and the TOXSCORE and slight rising trend of the relation of the serum CBZ to the degree of coma. The significance of this trend rose essentially at the serum CBZ levels of more than the median 38 micrograms/ml. The causes of the non significant correlation of serum CBZ (in particularly range) to the clinical condition is discussed. The individuals factors of the patient and possible effect of other, unknown drugs taken together with CBZ seem to play a minor role at the concentrations above 38 micrograms/ml. A very precise correlation has been found at the serum concentrations exceeding 40 micrograms/ml.

APACHE↗
PubMed1996

Scale and scope economies among health maintenance organizations.

We examine scale and scope economics among Group and IPA Health Maintenance Organizations (HMOs) over the period 1988 to 1991 using a national sample of HMOs. We allow for the multiproduct nature of HMO production by estimating the cost of producing a member month of non-Medicare and Medicare coverage, and we examine the effect of HMO market structure on costs. We find that HMOs benefit from scale economies. There are scope diseconomies associated with providing both non-Medicare and Medicare products. Group HMOs in more competitive markets have lower costs but IPA costs are not affected by competition.

Economic Competition↗
PubMed1996

Effect of mergers on health maintenance organization premiums.

This study estimated the effect of mergers on health maintenance organization (HMO) premiums, using data on all operational non-Medicaid HMOs in the United States from 1985 to 1993. Two critical issues were examined: whether HMO mergers increase or decrease premiums; and whether the effects of mergers differ according to the degree of competition among HMOs in local markets. The only significant merger effect was found in the most competitive markets, where premiums increased, but only for 1 year after the merger. Our research does not support the argument that consolidation of HMOs in local markets will benefit consumers through lower premiums.

Capitation Fee↗
PubMed1996

An analysis of selectivity bias in the Medicare AAPCC (adjusted average per capita cost).

Using econometric models of endogenous sample selection, we examine possible payment bias to Medicare Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) risk health maintenance organizations (HMOs) in the Twin Cities in 1988. We do not find statistically significant evidence of favorable HMO selection. In fact, the sign of the selection term indicates adverse selection into HMOs. This finding is interesting, in view of the fact that three of the five risk HMOs in the study have since converted to non-risk contracts.

Aged↗
PubMed1996

Economic and organizational determinants of HMO mergers and failures.

This study analyzed data from all operational health maintenance organizations (HMOs) in the United States from 1986 through 1993. Eighty HMOs disappeared through mergers and 149 failed over that period. We estimated a multinomial logit model to predict whether an HMO would merge and survive, merge and disappear, or fail, relative to the probability of no event. We found that enrollment and profitability play a critical role in explaining HMO mergers and failures: large and profitable HMOs were more likely to merge and survive, but less likely to merge and disappear or fail. These results explain why HMO merger and failure rates fell after 1988, as most surviving HMOs became larger and more profitable. Among several market-area variables in the model, state anti-takeover regulations had a negative impact on mergers. Mergers were more likely in markets with more competing HMOs, but the overall market penetration of HMOs had no effect on mergers. This result may have important implications for the current debate over the future of the competitive health care strategy. If public policy successfully stimulates the development of large numbers of new HMOs, another wave of mergers and failures is likely to occur. But it appears that growth in overall HMO penetration will not lead inevitably to increased market concentration.

Bankruptcy↗
PubMed1996

Rapid differential diagnosis of cerebral toxoplasmosis and primary central nervous system lymphoma by thallium-201 SPECT.

UNLABELLED: This study sought to assess whether 201Tl brain SPECT can significantly reduce the time required for the differential diagnosis of primary central nervous system (CNS) lymphoma and cerebral toxoplasmosis in patients with AIDS. METHODS: Eighteen patients who presented with focal lesions on CT or MRI, or both, underwent 201Tl brain SPECT shortly after admission and before a CT-guided stereotactic brain biopsy. Early and delayed 201Tl uptake ratios were obtained for patients with positive 201Tl study results, and the retention index of 201Tl was calculated. RESULTS: Ten patients had 11 foci of significantly increased 201Tl uptake in regions of corresponding CT/MRI lesions. Five of these patients had biopsy-proven lymphomas, one of them in two separate foci. Another patient was found to have metastatic adenocarcinoma. Three patients had a clinical course and response to radiation therapy consistent with lymphoma, and study results in another patient were considered falsely positive. Of nine patients with no 201Tl uptake in regions of CT/MRI lesions, two had biopsy findings consistent with a benign etiology, and the other seven improved clinically on antitoxoplasmosis medications alone. The overall sensitivity of 201Tl brain SPECT was 100%, and specificity was 90%. The 201Tl retention index in patients with lymphomas was significantly higher than that in patients with adenocarcinomas and nonmalignant lesions (1.35 +/- 0.16 versus 0.24 and 0.56, respectively). CONCLUSION: Thallium-201 brain SPECT is a sensitive and specific method for rapid differential diagnosis of CNS lymphoma and toxoplasmosis in patients with AIDS. The 201Tl retention index is useful in differentiating CNS lymphomas from other malignant and nonmalignant pathologies.

AIDS-Related Opportunistic Infections↗
PubMed1995

More rapid, complete, and stable coronary thrombolysis with bolus administration of reteplase compared with alteplase infusion in acute myocardial infarction. RAPID Investigators.

BACKGROUND: Early restoration and maintenance of normal (TIMI 3) blood flow during acute myocardial infarction is critical for optimal preservation of left ventricular function and survival. Recombinant plasminogen activator (r-PA, reteplase) is a nonglycosylated deletion mutant of wild-type tissue-type plasminogen activator (TPA) that has been shown to achieve more rapid and complete thrombolysis compared with other plasminogen activators in animal models. METHODS AND RESULTS: The RAPID Trial was designed to test the hypothesis that bolus administration of one or more dosage regimens of r-PA was superior to standard-dose alteplase (TPA) in achieving infarct-related artery patency 90 minutes after initiation of treatment. Six hundred six patients with acute myocardial infarction were randomized to one of four treatment arms: (1) TPA 100 mg i.v. over 3 hours, (2) r-PA as a 15-MU single bolus, (3) r-PA as a 10-MU bolus followed by 5 MU 30 minutes later, or (4) r-PA as a 10-MU bolus followed by 10 MU 30 minutes later. Coronary arteriography was performed at 30, 60, and 90 minutes after initiation of treatment and at hospital discharge. The 10 + 10-MU r-PA group achieved better 90-minute and 5- to 14-day TIMI 3 flow (63% [CI, 55% to 71%] versus 49% [41% to 57%], P = .019, and 88% [82% to 94%] versus 71% [63% to 79%], P < .001, respectively) than the TPA group. The TIMI 3 flow in the 10 + 10-MU r-PA group at 60 minutes was equivalent to that in the TPA group at 90 minutes (51 versus 49%). Global ejection fraction and regional wall motion in the 10 + 10-MU r-PA group were superior to those of the TPA group at hospital discharge (53 +/- 1.3% versus 49 +/- 1.3%, P = .034; -2.19 +/- 0.12 versus -2.61 +/- 0.13 SD per chord, P = .02, respectively). The 15-MU and 10 + 5-MU r-PA patency and left ventricular function results were similar to those of the TPA and inferior to those of the 10 + 10-MU r-PA group. Bleeding complications were similar between the groups. CONCLUSIONS: r-PA given as a double bolus of 10 + 10 MU achieves more rapid, complete, and sustained thrombolysis of the infarct-related artery than standard-dose TPA, without an apparent increased risk of complications. This was associated with improved global and regional left ventricular function at hospital discharge.

Coronary Angiography↗
PubMed1995

Utility of transvenous liver biopsies and wedged hepatic venous pressure measurements in sixty marrow transplant recipients.

Sixty marrow transplant recipients with liver dysfunction underwent transvenous liver biopsy and measurement of the hepatic venous pressure gradient. Biopsies were done on 29 patients using a Cook needle inserted through the jugular vein, on 30 patients through the femoral vein with a Mansfield biopsy forceps, and on 1 patient using both instruments. The average number of evaluable portal spaces was 4.0 for aggregated Cook needle specimens and 5.2 for Mansfield forceps specimens. The average number of central venules was 2.6 for Cook needle specimens and 3.5 for Mansfield specimens. Tissue obtained with the Mansfield forceps had crush artifact, especially along the edges, making assessment of bile ducts more difficult than in Cook needle specimens. Liver histology aided management in 53/60 patients by confirming the clinical diagnosis in 24 (40%) and by providing additional diagnoses in 29 (48%). Hepatic venous pressure gradient > 10 mmHg correlated with a histologic diagnosis of veno-occlusive disease (P = 0.001); this gradient value provided 91% specificity and 86% positive predictive value. Eleven patients had bleeding complications, 9 after Cook needle biopsy and 2 after Mansfield forceps biopsy. There were 3 procedure-related deaths, 2 from intraperitoneal bleeding after Cook needle biopsy and 1 from femoral vein bleeding after Mansfield biopsy. We conclude that transvenous liver biopsy and pressure measurements provide useful diagnostic information in marrow transplant patients with liver disease. In our hands, the Mansfield forceps was associated with a lower risk of intra-abdominal bleeding and capsular perforation of the liver while providing adequate histology for diagnosis. Hepatic venous pressure gradients > 10 mmHg were highly specific for a diagnosis of veno-occlusive disease in this patient population.

Biopsy↗
PubMed1995

The effect of market structure on HMO premiums.

We examine the effects of HMO market structure on HMO premiums from 1988 to 1991. More competition, measured by the number of HMOs in the market area, reduces HMO premiums. Although this effect does not appear for IPAs before the highest level of competition is reached, it appears throughout the competitive range for Group HMOs. More market penetration, measured by the percent of the market area population enrolled in HMOs, reduces premiums for IPAs. Since the goal of managed competition is to reduce health care costs by creating competition among managed health care plans, our results offer encouragement for managed competition advocates.

Capitation Fee↗
PubMed1995

Does publishing the parameters that trigger review of Medicare claims change provider behavior? Results of the parameter release study.

In April 1989, the Health Care Financing Administration stopped publishing the parameters that trigger review of Medicare claims because they thought that knowledge of the parameters would permit providers to schedule visits to avoid review. In this article, the authors report the results of an experimental study where previously unrevealed parameters were revealed to some providers of Medicare services and not to others. The authors find little evidence to suggest that providers schedule procedures to avoid review when they know the parameters. There is some evidence, however, that providers may be responding to the release of the parameters in other ways.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Open-ended options in Medicare risk contracts with HMOs.

The open-ended option has achieved broad acceptance in the health maintenance organization (HMO) industry. Permitting HMOs that enter into risk contracts with Medicare to offer open-ended products would expand the number of managed care options available to Medicare beneficiaries. The attractiveness of this option to HMOs depends in part on how issues are addressed relating to tracking and managing of out-of-plan use, education of Medicare beneficiaries, interface with peer review organizations (PROs), payment of nonnetwork providers, and use of medical screening. Perhaps most importantly, changes in the Medicare supplementary insurance market probably would be necessary before an open-ended product would be offered by HMOs under Medicare risk contracts.

Contract Services↗
PubMed1994

Measuring the dimensions of physician work.

Medicare has adopted a physician fee schedule that places emphasis on measuring physicians' work. We assessed the construct validity of self-reported work scores for 11 selected medical services performed by 44 internists in two large group practices. These physicians' work scores correlated highly with their ratings of time, physical and mental effort, and stress required to produce the services. Eighty-five percent of the variance in total work scores could be explained by the dimensions of work. Time was the most important input, but mental effort also was important for internists. We also found that physicians may reduce the total work required to produce two services for a patient if they provided those services in one visit, rather than in separate visits. Savings occurred for service pairs in which the physician could reduce his or her own time. Our findings imply that the Medicare fee schedule pays internists mainly for the time and mental effort required to produce medical services. They also underscore the importance to physicians of saving time by providing two services during the same patient visit.

Cost Savings↗
PubMed1994

Health plan choice in the Twin Cities Medicare market.

This paper examines the relationship between characteristics of Medicare beneficiaries and their choice of health plan in the Twin Cities during 1988. This analysis provides the first comparison of beneficiaries in the basic fee-for-service (FFS) Medicare sector (without a supplementary policy) to beneficiaries in the FFS sector with a supplementary policy, enrollees in independent practice associations (IPAs), and network health maintenance organizations (HMOs). The site and time period are important because there were five large, mature HMOs with TEFRA-risk contracts operating at that time, enrolling 50% of Medicare beneficiaries in the market area. We find that the oldest, poorest and, to a lesser extent, the sickest Medicare beneficiaries were most likely to have basic FFS Medicare coverage without supplementary insurance. The youngest enrollees are found in network HMOs. The availability of group coverage and premium subsidies are positively associated with choice of FFS with a supplementary policy. Government policy concerning Medicare HMO premiums appears to contribute to the poorest beneficiaries facing the highest out-of-pocket costs.

Age Factors↗