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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↗
PubMed2002

Trends in glaucoma surgery incidence and reimbursement for physician services in the Medicare population from 1995 to 1998.

OBJECTIVE: To better understand the relationship between glaucoma management and economic incentives, we examined the volume and the reimbursement of argon laser trabeculoplasty (ALT) and trabeculectomy in a 5% random sample of the Medicare population from 1995 to 1998. DESIGN: Retrospective cohort study. PARTICIPANTS: Subjects in a 5% random sample of the Medicare population who had ALT and trabeculectomy from 1995 to 1998. METHODS: Using the Health Care Financing Administration (HCFA) Physician/Supplier Part-B files for a 5% random sample of the Medicare population, we identified all subjects who had ALT and trabeculectomy from 1995 to 1998. Descriptive summaries (the number of surgeries and the mean and the standard deviation of reimbursement per surgery) were calculated for each year. Analysis of variance was used to test for differences in reimbursement per surgery across years. Chi-square tests were used to assess any associations between the changing numbers of ALTs and trabeculectomies over the study period and both age and race. MAIN OUTCOME MEASURES: We assessed the number of ALTs and trabeculectomies and the allowed charges for each surgery in the 5% random sample of the Medicare population from 1995 to 1998. RESULTS: The volume of both ALTs and trabeculectomies declined during the study period. Reimbursement per surgery for both ALT and trabeculectomy varied significantly across years (P < 0.001). Significant associations were found between the changing number of ALTs and both age and race. CONCLUSIONS: Changing numbers of ALT and trabeculectomy seem unrelated to reimbursement rates. Rather, these changes are more likely driven by new developments in the clinical management of glaucoma, among other factors.

Aged↗
PubMed2001

Coding and reimbursement issues for the radiologist.

Radiologists are dependent on the proper execution of a complex administrative chain of disease and diagnosis coding and procedural coding to be properly reimbursed for the examinations they perform. The radiologist bears the ultimate responsibility for the appropriateness of these codes. However, many practicing radiologists are unaware of the critical link between the two coding systems and the systems that have developed to provide a common method of describing diseases, diagnoses, and procedures. This article is an introduction to these systems, and it emphasizes the importance of the involvement of the radiologist in coding. The inherent complexity of the reimbursement system in use is emphasized, as well as the essential role of the radiologist in complying with these often complicated and ever-changing directives.

Electronic Data Processing↗
PubMed1990

Restrictive reimbursement policies and uncompensated care in California hospitals, 1981-1986.

To examine the effect of restrictive state, federal, and private hospital reimbursement policies in California, we examined trends in uncompensated care and other deductions from hospital revenues from 1981 to 1986. During a period when the number of uninsured in California increased substantially, uncompensated care grew, but not as rapidly as other deductions from revenue, especially Medi-Cal and private-sector contractual allowances. A trend toward redistribution of uncompensated care from public to private hospitals reversed. Voluntary teaching hospitals, whose Medi-Cal and private-sector contractual allowances grew rapidly, recently reported a decline in uncompensated care. As reimbursement pressures increase, private hospitals may resist pressures to provide uncompensated care, increasing the burden on public institutions and perhaps limiting the access of indigents to quality care.

California↗
PubMed1979

Maximum allowable cost: can the government control drug costs?

In 1973 the federal government moved to limit drug reimbursement to providers in federally sponsored or supported programs, to the lowest cost at which the drug is generally and consistently available unless a difference in therapeutic effect can be demonstrated between the brand name and generic drug. This paper examines the political evolution and rationale for this program and explores the issues surrounding the ongoing controversy regarding publicly financed programs offering drug benefits. The authors speculate that the government's first attempt to control prices of pharmaceuticals, prior to enactment of some form of national health insurance, if successful, will call forth pharmaceutical industry strategies which could negate program benefits.

Cost Control↗
PubMed1981

Analysis of services received under Medicare by specialty of physician.

This paper examines use of physicians' services by Medicare beneficiaries according to the specialty of the physician providing care. The major objectives of this study were to determine which types of physicians are most frequently used, the average charge per service by specialty, the mix of physicians (by specialty) that patients saw during the year, and the amount Medicare reimburses in relation to total physician income. Data were studied for the total Medicare population and by age, sex, race, and geographic area. Claims data for 1975 and 1977 were used from the Part B Bill Summary System. This system collects information from bills from a 5 percent sample of Medicare enrollees. Major findings from this study indicate: (1) Physicians in general practice and internal medicine provided about the same number of services and each far outranked all other types of physicians in numbers of Medicare beneficiaries with reimbursed services. (2) There were marked differences by census region in the use of certain specialists, particularly pathologists, podiatrists, dermatologists, and the specialty group otology, laryngology, rhinology. (3) Average charges per service varied considerably by specialty. Internists' charges averaged 35 percent higher per service than charges by general practitioners. Charges submitted by the surgical specialties far outranked all others and showed the greatest increase during the period under study. (4) Of the total persons with reimbursement physicians' services in 1977, 85 percent saw a primary care physician during the year, while the remaining 15 percent received services from specialists only. (5) Of the total reimbursements made by Medicare, internists received 20 percent, general practitioners received 14 percent, and general surgeons 12 percent. Medicare's payments were estimated to be 21 percent of total gross income for internists, 20 percent for anesthesiologists, and 18 percent for surgical specialties.

Economics, Medical↗
PubMed2002

The cost of angiography procedures: OHIP gets a bargain.

OBJECTIVE: To determine the costs for 1000 randomized interventional angiographic procedures. METHODS: An 9-page paper form was used to manually record the consumables, technologist time, room occupancy time and recovery room time for 80 different procedures collected over a 2-year period. The average cost for expendables per procedure was calculated for procedures that occurred 5 or more times. RESULTS: Of the 1000 procedures surveyed, there were 20 that had 10 or more occurrences, 9 that occurred 5-9 times and 51 that occurred less than 5 times, of which 32 had only a single occurrence. The total expendables used were $514,008. The total examination time was 1158 hours. The total technologist time was 2493 hours, and the total recovery room time was 1806 hours. Examples of the average cost per procedure are: cerebral angiogram (n = 249), avg. cost $441.24, and transvenous liver biopsy (n = 30), avg. cost $642.89. The coefficient of variation for procedure costs ranged from 15% to 139%. There were no correlations of technician time or procedure technical cost with the date of scan, indicating that there was no systematic increase or decrease in costs over the survey period. There were moderate correlations of the technical cost of a procedure with technologist time (Pearson r = 0.69) and the duration of a procedure (Pearson r = 0.73). The technical costs of interventional procedures were significantly underfunded; the reimbursement from the Ontario Hospital Insurance Plan was $278,446, or 54% of the actual costs. Fourteen procedures were reimbursed at below 50% of their costs. CONCLUSION: This shortfall in funding has serious consequences for the types and numbers of procedures that are possible in radiology departments. Funds must be diverted from other places to prevent serious rationing of these services.

Angiography↗
PubMed2004

Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations.

OBJECTIVE: To compare the results of a randomised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting. DESIGNS: Cluster randomised controlled trial and observational time series with historical controls. SETTING: Pharmacare, the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia, Canada. PARTICIPANTS: In the randomised controlled trial 104 clusters of medical practices, pair matched by geography and approximately by practice size, were randomised to the intervention group (449 patients affected by the policy on 1 March 1999), and the control group (offered a six month exemption, affecting 386 patients). The observational analysis included all Pharmacare beneficiaries (excluding the 386 exempt patients) who had used any nebulised drugs six months before the policy (4624 patients). INTERVENTION: Pharmacare restricted reimbursement for nebulised bronchodilators, steroids, and cromoglycate to patients whose doctors applied for an individual patient's exemption, giving an appropriate clinical reason. MAIN OUTCOME MEASURES: Number of contacts with doctors and services, emergency admissions to hospital, and utilisation of and expenditure for respiratory drugs in databases of British Columbia's Ministry of Health. RESULTS: Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction, regardless of the analytical approach. In the observational analysis, we found a reduction of C24 dollars per patient month in all nebulised drug use (95% confidence interval 19 to 29) and an increase of C3 dollars per patient month in all expenditure for inhalers (1.4 to 4.5). The randomised evaluation found savings of C8 dollars per patient month for nebulisers (P = 0.24) and no increase in spending on inhalers (P = 0.79). Correcting for 60% non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation. CONCLUSIONS: Observational as well as randomised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs. Randomised policy trials are feasible and, if carefully implemented, likely to be concordant with observational evaluations.

Administration, Inhalation↗
PubMed2000

[Cardiologists and limitations of statins reimbursement].

BACKGROUND: In Italy of five approved HMG-CoA reductase inhibitors (atorvastatin, cerivastatin, fluvastatin, pravastatin, and simvastatin) only the last two are reimbursed by the National Health System for secondary prevention of coronary artery disease. METHODS: During the 1999 Annual Meeting of the National Association of Hospital Cardiologists (ANMCO) a questionnaire was included in the meeting material. The aim was two-fold: 1) to evaluate whether Italian cardiologists approve the National Health System policy to reimburse only pravastatin and simvastatin for secondary prevention, and 2) to assess which end-points are considered sufficient to grant the reimbursement of additional HMG-CoA reductase inhibitors. RESULTS: Two hundred and thirty-two completed questionnaires were collected and analyzed: 90.1% (95% confidence interval-CI between 85.1 and 93.6%) of cardiologists agree that only HMG-CoA reductase inhibitors with evidence-based mortality reduction should be reimbursed in Italy for secondary prevention; 75.0% (95% CI between 69.4 and 80.6%) follow the State guidelines in order to choose the approved HMG-CoA reductase inhibitors and 69.4% (95% CI between 63.5 and 75.3%) judge that at least the demonstration of coronary artery plaque reduction should be considered as an evidence-based decision to include new HMG-CoA reductase inhibitors for reimbursement. CONCLUSIONS: Most of Italian cardiologists who answered the questionnaire agreed with the limitation of reimbursement to only HMG-CoA reductase inhibitors with evidence-based demonstration of mortality reduction and asserted that the only reduction in blood cholesterol levels should not be considered proof of efficacy.

Adult↗
PubMed1995

Questions and answers on health insurance benefit issues.

This Issue Brief addresses eight topics in the areas of health insurance and health care costs. Using a question and answer format, the discussion draws largely on EBRI research and the EBRI Databook on Employee Benefits, third edition. In 1993, U.S. expenditures on health care were $884.2 billion, and they are projected to reach $2,173.7 billion by 2005, increasing at a projected average annual rate of 7.8 percent. Health care spending accounted for 13.9 percent of Gross Domestic Product (GDP) in 1993 and is projected to reach 17.9 percent of GDP by 2005. Among the factors contributing to the increase in health care costs are the growth in the number of individuals with traditional reimbursement health insurance coverage, the rapid expansion of technology and treatment options, and demographic factors such as the aging of the population. In 1993, employers, both public and private, spent $235.6 billion on group health insurance, accounting for 6.2 percent of total compensation. Group health insurance is the fastest growing component of total compensation, increasing at an average annual rate of 13.7 percent from 1960 to 1993. An increasing number of employees are required to make a cash contribution to their health insurance plan premium. In 1993, 61 percent of full-time employees in medium and large private establishments who participated in an employee only health insurance plan were required to make a contribution to the premium, up from 27 percent in 1979. In 1993, 185.3 million persons under age 65 had health insurance coverage, while 40.9 million people--or about 18.1 percent of the nonelderly population--received neither private health insurance nor publicly financed health coverage. Of those individuals who had health insurance coverage, 60.8 percent, or 137.4 million persons, received their health insurance through an employment-based plan. In 1993, 15.2 percent of the nonelderly population without health insurance coverage were noncitizens. In six states noncitizens represented a higher proportion of the total uninsured population than individuals in the nation as a whole. An increasing number of employers are self-funding their health insurance plans. In 1994, 74 percent of employers with 500 or more employees self-funded their health insurance plans, up from 63 percent in 1993. An estimated 22 million full-time employees in private industry and state and local governments participated in a self-funded employment-based health insurance plan.(ABSTRACT TRUNCATED AT 400 WORDS)

Data Collection↗
PubMedDate not supplied

Reimbursement challenges for emergency physicians.

Emergency physicians are under growing fiscal pressures on multiple fronts. Federal and state laws require that emergency care be provided to all those presenting at an emergency department, yet in nearly all cases there is no comparable mandate for reimbursement. The growing number of uninsured and underinsured, as well as downward pressure on reimbursement from managed care organizations and social assistance programs such as Medicaid and Medicare, also contributes to the difficulty of emergency physicians to be compensated. It may be time for the public to address more fundamental questions about the right to care and who pays for that care.

Cost Allocation↗
PubMed1988

The future of family practice. Implications of the changing environment of medicine. Council on Long Range Planning and Development in cooperation with the American Academy of Family Physicians.

The Council on Long Range Planning and Development of the American Medical Association has identified trends in the environment of medicine and the implications of these trends for specific medical specialties. This report considers the evolution of family practice as a specialty and its role in the future of health care delivery. As a specialty established less than 20 years ago, family practice has successfully surmounted several obstacles to achieve recognition within the medical community and among the public. However, the Council has identified new challenges and opportunities facing this specialty. In particular, the areas of graduate medical education, reimbursement, professional liability, and several health-related societal and ethical issues will pose challenges for and place constraints on family physicians. Family practice will encounter a number of opportunities in the evolving environment of medicine, due in part to demographic trends in the population and the growth in managed care. The Council concludes that, despite the challenges, the increasing demand for the services of family physicians has positive implications for the future of this specialty.

Education, Medical, Graduate↗
PubMed2004

Three scenarios of clinical claim reimbursement for nosocomial infection: the good, the bad, and the ugly.

We studied the extent to which hospitals can expect to receive reimbursement for costs relating to nosocomial infections (NI) under the diagnosis-related groups (DRG) system of clinical claims and calculated the loss of reimbursement due to missed or incorrect registration of infective complications on hospital discharge records (HDR). We calculated clinical claim reimbursement in three scenarios: the good, in which all NI are recorded on HDR; the bad, in which a proportion of NI recorded on HDR observed at the 41 participating hospitals; the ugly, in which none of the NI are recorded on HDR. We analysed in which patients the recording of infective complications changed the DRG clinical claim and the economic consequences on reimbursements. Compared with the ugly scenario, the bad scenario, which is closest to what actually occurs, with only 55.9% of NI (180/322) properly recorded, produced an increased DRG clinical claim in 30 cases, of on average 403 for every NI. Compared with the ugly scenario, the good scenario, produced an increased DRG clinical claim in 45 cases with an average reimbursement of 618. The difference between the bad and the good scenarios shows an average loss of 215 for every case. Our calculated good scenario could cover only 3.8% of direct costs per case attributable to NI. Real, tangible benefits in health, both social and economic, will only accrue from the monitoring and control of NI in hospitals.

Cross Infection↗
PubMed1994

The pricing and reimbursement of pharmaceuticals.

This paper identifies common research themes arising from the papers on the pricing and reimbursement of pharmaceuticals presented elsewhere in this supplement. These include the following: How effective has cost containment been? What is the base case against which this is measured? Is there any evidence that research and development is changing in value or character as a result? How can the implied contract between government and industry be made more explicit to avoid opportunistic behaviour?

Drug Costs↗
PubMed1979

Paying for physician services under Medicare and Medicaid.

Public systems for physician reimbursement aim to reconcile two disparate objectives: ensuring availability of services to the poor and aged; and keeping rates of cost increase within acceptable limits. Several interesting--and unorthodox--policy simulations of physician pricing behavior are investigated through econometric estimation. Current arrangement for paying physicians are fraught with difficulties. The objectives of Medicare and Medicaid are not well served.

Aged↗
PubMed1993

Financial impact of thoracoabdominal aneurysm repair.

We have reviewed our experience regarding hospital costs and reimbursement for 72 patients who underwent thoracoabdominal aneurysm repair. Preoperative risk factors, postoperative complications, length of stay, and source of reimbursement were recorded for all patients. Patients covered by Medicare resulted in a mean net institutional loss of $16,472 per patient, whereas a mean net profit of $17,847 per patient resulted from patients with commercial insurance. Factors associated with institutional financial loss were: age over 75 years, preoperative coronary disease, postoperative respiratory failure, and length of stay. By multivariate analysis, however, only length of stay was independently associated with institutional loss.

Adult↗
PubMed1995

[Rehabilitation and social reintegration of cancer patients].

In France, social laws permit a total reimbursement of medical and pharmaceutical expenses for cancer patients. Income is also supplied to cancer patients by the National health service or the state to compensate for the absence of salary during a time period without being for civil servants or employees. Civil servants can be absent from their job without being dismissed for 5 years, at most, for cancer reason. For employees, or workers this time period is shorter, varying from one company to another according to local agreements. Several public organisations can help a previous cancer patient to return to work and the percentage of patients working again is good except for poorly qualified employees or workers due to the economic crisis. New laws allow cancer patients to be civil servants except if the disability does not fit with his job. The possibility of life insurance of cured patients depends on the site of cancer, the prognosis, the treatment sequellae and the delay between the treatment completion and the request.

Employment↗