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PubMed1999

Reimbursement of enoxaparin for outpatient therapy. Proceedings of regional meetings.

Standard treatment of deep venous thrombosis (DVT) previously required hospitalization so patients could receive continuous intravenous infusion of unfractionated heparin. However, on Dec. 31, 1998, enoxaparin (enoxaparin sodium) became the first low-molecular-weight heparin (LMWH) to receive an indication from the FDA for outpatient treatment of DVT without pulmonary embolism (PE). The manufacturer of enoxaparin, Rhône-Poulenc Rorer (RPR), states that outpatient use of enoxaparin can help managed care organizations (MCOs) and other health care systems to reduce health care costs by curtailing some of the expenses previously associated with hospitalization to treat uncomplicated DVT. To ascertain the extent to which reimbursement policies within managed care might impede patients' access to enoxaparin, RPR conducted 15 regional meetings during the summer of 1999. During these meetings, medical directors and other personnel associated with MCOs provided anecdotal information suggesting that a dominant method of reimbursing enoxaparin for outpatient therapy has yet to emerge in the United States; and that reimbursement methods appear to be divided equally among the pharmacy benefit, the medical benefit, and a "blended" system combining attributes of the pharmacy and medical benefits.

Ambulatory Care↗
PubMed1994

Pricing and reimbursement of pharmaceuticals in Sweden.

Significant changes in the Swedish reimbursement system for drugs were introduced on January 1, 1993. A reference price system was introduced and price control became the responsibility of the National Social Insurance Board (NSIB). If a drug is to be reimbursed when prescribed, the price must be approved by the NSIB. The prices for drugs included in the reference price system do not have to be approved by the NSIB, as the reimbursement level is fixed at 10% above the price of the cheapest generic. Several pricing strategies were developed by pharmaceutical companies after these changes. For original products within the reference price system, the price, with few exceptions, was dropped to the reimbursement price. Total sales for compounds with reference prices decreased in value and the market share for generic products increased. Some products and package sizes, mainly with regard to hospital drugs, were withdrawn from reimbursement and the prices increased. The total sales of drugs for human use increased by about 6.5% during the first 6 months of 1993 when compared with the same period the previous year. There was a slight decrease (1.6%) in total expenditure for the reimbursement scheme (NSIB), but an increase of 14% for patient copayments during the first 3 months compared with the same period the year before. Cost containment has become a major priority for all publically financed programmes. However, the changes in the Swedish drug reimbursement system have not produced significant savings in public expenditure and further changes may be expected.

Cost Control↗
PubMed2000

Cost containment of pharmaceutical use in Iceland: the impact of liberalization and user charges.

OBJECTIVES: Iceland was the first Nordic country to liberalise its drug distribution system, in March 1996. Subsequent regulation in January 1997 increased patients' share of drug costs. The objectives of this study were to test the assumptions that liberalizing community pharmacy ownership would lower reimbursement costs for the state's Social Security Institute and that increasing patient charges would reduce use and, therefore, lower the cost to the Institute. METHODS: Based on the assumptions, we built and tested two models using interrupted time series designs that contrast the monthly reimbursement costs before and after the legislation and regulation took effect. A control variable (the number of office visits to general practitioners) was tested to assess other events in the health care arena. Monthly data on these variables were provided by the Icelandic State Social Security Institute for January 1993 to August 1998 for reimbursement costs and to December 1998 for office visits to general practitioners. RESULTS: Reimbursement costs have risen steadily throughout the period under study. The interrupted time series analysis did not show a substantial effect from the legislative change in March 1996 or from the regulatory intervention in January 1997. CONCLUSIONS: The main argument used for liberalizing community pharmacy ownership in Iceland was built on false assumptions regarding the effect on drug reimbursement costs to the state. It will be necessary to find more promising interventions to halt the rapidly increasing cost of drugs.

Cost Control↗
PubMed2007

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.

BACKGROUND: Previous studies have documented that hospitals decrease costs in response to reimbursement cutbacks. However, research concerning how this may affect quality of care has produced mixed results. Until recently, the ability to study changes in patient safety and payment has been limited. OBJECTIVE: The objective of the study was to determine whether changes in 4 hospital patient safety indicator (PSI) rates are related to changes in the generosity of payers over time. DATA AND METHODS: Study data are drawn from 1995-2000 hospital discharges in 11 states in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database. Following the same organizations over time, we estimate hospital fixed-effects regression models of the association of payer-specific time and post Balanced Budget Act (BBA) payment changes with risk-adjusted hospital PSI rates controlling for patient, organizational, and market characteristics. Four PSIs relevant to a large number of patients and hospitals that reflect general care processes are studied. RESULTS: The time trend during 1995-2000 is consistently significantly positive for private and Medicare hospital PSI rates. Thus, after controlling for patient characteristics and organizational and market factors, performance worsened. The trend is less consistent for Medicaid and does not exist for self-pay hospital PSI rates. After adjusting for multiple comparisons, we also find that the Medicare trend is fairly consistently higher than that of the other payers. In contrast, there is a less consistent BBA effect, especially for Medicare.

Financing, Personal↗
PubMed2001

Casemix reimbursement: a Singapore Children's Hospital perspective.

INTRODUCTION: Casemix reimbursement was introduced to Singapore in October 1999 using the Australian National Diagnosis Related Groups Version 3.1 (AN-DRGs 3.1). The possible impact of this classification system on a Singapore Children's Hospital is discussed. MATERIALS AND METHODS: Data on paediatric patients in KK Women's and Children's Hospital (KKH) were drawn from the inhouse Datamart warehouse system, and reviewed with regards to volume of patients, length of stay and charges. Several high cost categories were selected for a more in-depth review and discussed. RESULTS: The classification system and reimbursement method did not take into account the higher cost of treating children, thus penalising the Children's Hospital. The wide variety of cases treated also gave rise to difficulty in obtaining appropriate reimbursement. The lack of severity of illness measures was a drawback in the Diagnosis Related Group (DRG) for ventilated patients. The lack of outcome measures gave rise to potentially inequitable reimbursement in some high cost neonatal DRGs. CONCLUSION: While Casemix is an improvement over previous methods of providing Government funding in Singapore, particular aspects need to be reviewed, and reimbursement criteria refined to ensure equitable funding to Children's Hospital.

Adolescent↗
PubMed1992

Direct access use by experienced therapists in states with direct access.

Direct access use among experienced therapists practicing in states with 3 years' experience with direct access was studied, as were differences between therapists who had and had not practiced through direct access. A questionnaire was mailed to 250 members of the North Carolina, Nevada, and Utah chapters of the American Physical Therapy Association. Almost half (44.5%) of the respondents had practiced through direct access; an estimated 10.3% of their caseload was seen through direct access. Reasons for not practicing through direct access were that the employer does not permit direct access practice (49.1%), insurance does not reimburse for direct access practice (43.6%), no patients have been seen without referral (25.5%), and personal preference to treat by referral only (23.6%). Therapists who had treated patients through direct access were significantly more likely to believe that direct access had benefited them professionally and benefited their patients than were therapists who had not practiced through direct access.

Health Services Accessibility↗
PubMed2006

The big squeeze. Insurers point to slower growth in premiums in past few years to show progress, but providers say they're paying the price.

While insurers last week were trumpeting the third straight year of slower growth in premiums, providers weren't exactly celebrating. That's because of huge mergers, which give insurers far more leverage and have led to reimbursements being cut back even more. "What's worrying us is that there's a growing segment (of insurers) that aren't going to budge an inch, no matter what," says Russ Weaver, left.

Cost Savings↗
PubMed1993

Restructuring American health care financing: first of all, do no harm!

Health care costs are climbing throughout the western world. Aging populations and the costs of advanced technology are the principal forces behind much of this global increase. No country has yet succeeded in containing these growing costs other than by some form of rationing. A variety of experimental strategies, including managed competition, are being considered or tested, but none is clearly effective. American health care expenditures differ, not in that they are rising, but in their enormously high starting point. Among other things, our higher costs reflect administrative costs of more than 20%, double those of Canada and nearly triple the European average; a malpractice system that, whatever its possible advantages, costs more than 10 times as much as it pays out to the injured; the enormous medical costs of poverty; maldistribution of physician specialties and incomes; and reimbursement systems that eliminate consumer input and oversight. Restructuring the system of health care financing to bring administrative costs in line with those of other nations could save at least $70 billion annually; another $25 billion or more could be saved by replacing the malpractice system with more cost-effective alternatives. These savings could defray the costs of insuring all those not now covered, without increasing either costs to the middle class, through taxation of benefits, or total health care expenditures. With all Americans covered, the necessary restructuring of the system of health care delivery could be conducted without the current pressure for immediate drastic reform, which carries with it the risk of serious error. In dealing with the sick, physicians are taught to apply two maxims: "primum non nocere" or "first of all, do no harm!"; and the rule of therapeutic restraint. The latter states that a severe chronic illness may respond better, and with fewer complications, to gradual corrective measures than to highly aggressive therapy. Both rules could well be applied to curing the American health care system.

Delivery of Health Care↗
PubMed1997

Empiric examination of physician behavior in a changing healthcare market.

We hypothesized that, in the current healthcare environment, medical providers have strong economic incentives to introduce new technology and treat patients more extensively. We examined physician reimbursement for medical procedures in Utah in the early 1990s, a period of increasing utilization of managed care methods, using a cross-section time series and a supply side model to analyze how physician behavior changed during this period of time. Our findings suggest that physicians have acted to maintain their revenue by requesting reimbursement for more procedures as the reimbursement level per procedure decreased. We conclude that increased volatility in reimbursement levels and increased adjudication pressure from payers provide signals to physicians to act strategically to protect their revenue stream.

Cost Control↗
PubMed2003

[Drug expenditures of pensioners in 1997-2000].

The general purpose of the study, carried out in the group of pensioners was to determine the relation between drug prices, household income and amounts of money spent on drugs in the years 1997-2000. The study was based on representative data gathered from annual household budgets review by Polish Statistical Office and data from pharmaceutical market published in 'Vitamina C++' magazine. The used method combined descriptive, comparative, table-descriptive analysis with graphical analysis. During studied period the real value of expenses on drugs in pensioners' households rose by 39.3% and available income decreased by 5.8%. Increased expenses on drugs caused the rise of the proportion of on spending on drugs in total household expenditure. It rose from 3.9% in 1997 to 5.2% in 2000. Throughout this time period the drug prices increased in real terms: the highest growth (approx. 49%) was noticed in patients' co-payment to reimbursed drugs. Despite rise in spending on drugs, due to the increase in drug retail prices and increasing patients co-payment, pensioners in comparison with 1997, could buy only approx. 93% units of reimbursed drugs in 2000. The possibility of buying drugs within OTC group increased by 18%.

Aged↗
PubMed1989

Swing-bed hospital cost and reimbursement.

Small rural hospitals can provide long-term care in acute care beds as part of the National Swing-Bed Program enacted in 1980. Medicare reimbursement for swing-bed care is based on the incremental cost concept. This article estimates the incremental cost to hospitals of swing-bed care and assesses the adequacy of swing-bed reimbursement in light of those estimates. Other swing-bed reimbursement policy issues are discussed, including payment for ancillary services, potential bundling of routine and ancillary reimbursement, and the possible incorporation of case mix into swing-bed payment determination.

Ancillary Services, Hospital↗
PubMed1978

Personality assessment and insurance reimbursement.

A contract between APA and OCHAMPUS has committed APA to developing a national peer review capability for the review of out-patient psychological services. This paper describes the review criteria which apply to personality assessment and psychological testing.

Humans↗
PubMed1993

Coding, documentation and dollars.

Physicians would like to get reimbursed for the services they perform. Unfortunately, many of them are not very good at documenting what they do. The result is that physicians are being reimbursed far less than what they should be or are being asked to refund reimbursement for services they cannot substantiate. The financial impact to the physician's practice can be enormous. For many years, physicians have viewed HIM professionals as adversaries. There now exists the opportunity for HIM professionals to become allies with physicians by helping them obtain and maintain the reimbursement they are entitled to. Physicians have the need, and HIM professionals have the knowledge and skill. It is up to our profession to show them what we can do.

Abstracting and Indexing↗