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At least 217 records · Page 12Linked to original sources
PubMed2004

Outpatient laparoscopic hysterectomy in a rural ambulatory surgery center.

STUDY OBJECTIVE: To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques. DESIGN: Prospective feasibility and observational study (Canadian Task Force classification II-3). SETTING: Rural ambulatory surgery center in Lamar, Alabama. PATIENTS: Fifty-two women. INTERVENTION: Outpatient laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 79 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary. CONCLUSION: Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.

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↗
PubMed2003

Overview of inpatient coding.

The main classification-based and nomenclature-based coding systems used in the United States, as well as the process and importance of documenting in the patient record, are discussed. Hospital pharmacists usually have limited knowledge of and exposure to coding and reimbursement in the inpatient system. Coding allows for reporting of mortality data to the World Health Organization (WHO), reporting morbidity data in the U.S., and providing data for reimbursement from third-party payers to hospitals for services provided. Coded information is also the primary source for administrative management of medical services and a source of epidemiologic and statistical data from inpatient stays. In order to better understand inpatient coding and reimbursement, this article will discuss the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding system; the Healthcare Common Procedure Coding System (HCPCS); the process and importance of appropriate chart documentation; and the development of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system. Coding in the inpatient setting enables hospital billing and provides statistical data for epidemiology and financial planning. The ICD-9-CM is a clinically modified version of the international ICD-9 system used for coding both diagnoses and procedures in the United States. Coding is derived from documentation found in the patient's chart. Appropriate documentation is key for quality and continuity of care and compensation for resources utilized. In the future the ICD-9-CM will be replaced by the 10th revision, ICD-10, which is already in use in many countries in Europe.

Abstracting and Indexing↗
PubMed1983

Utilization of hospital services: the roles of teaching, case mix, and reimbursement.

This study examined the role of hospital teaching affiliation, third-party payer mix, physician compensation, and case mix on the utilization of inpatient services. Using multivariate analysis with five different utilization measures, we found that: 1) the level of teaching activity and commitment to teaching had no significant effect on the scope of inpatient service utilization; 2) self-pay patients were low utilizers whereas Medicaid patients were high utilizers; 3) inpatient utilization appeared to be lower when physicians were compensated on a salaried basis; and 4) case mix had a significant impact on inpatient utilization.

Clinical Laboratory Techniques↗
PubMed1985

Subsidizing pharmaceutical prescriptions: the experience of Denmark, Finland, Norway and Sweden.

In 1980, drug consumption per capita was 455 Swedish crowns (SEK) in Sweden, SEK 452 in Denmark, SEK 384 in Finland and SEK 382 in Norway; actual figures for Denmark, Finland and Norway being converted into Swedish crowns using the mean 1980 exchange rates. To what extent can these differences be explained by differences in the drug reimbursement programmes of these four Nordic countries? For instance, is it the greater generosity of the Swedish system--in Sweden, the share of drug reimbursement expenditures to total drug consumption is 57%, as against 33% in Norway, 38% in Finland and 34% in Denmark--that makes drug consumption per capita so much higher in Sweden? If the demand for drugs were elastic and if all other influencing factors, besides the reimbursement system, were the same in all the four Nordic countries, then a definite conclusion would, obviously, be fairly easy to reach. However, a number of factors do differ: for instance, income per capita, physician remuneration schemes (and, hence, maybe, physician behaviour) and consumer charges for inpatient and outpatient care; and other factors such as morbidity and patterns of illness may differ. A complete analysis has to take all these factors into account. Too many factors seem to vary to make the sole use of cross-section data meaningful in this case. Time-series data are available and will be used in future analyses.

Cost Control↗
PubMed1978

Payment for nondistributive hospital pharmacy services--a regional survey.

Questionnaires were mailed to all (464) nongovernment, not-for-profit and investor owned for-profit hospital pharmacies in Washingon, Oregon and California. Responses were received from 350 institutions, a return rate of 75.4 percent. Pharmacists were asked to report data relating to the incidence of, the range of fees charged, and the extent of reimbursement received from third party carriers for the provision of nondistributive pharmacy services. The data received indicate that pharmacy consultation to physicians was provided by 77.9 percent of the respondents, drug therapy monitoring by 48.1 percent, generalized patient discharge consultation by 40.8 percent, CPR team participation by 27.2 percent, indepth patient discharge consultation by 17.5 percent and admitting medication history by 8.8 percent. Additionally, 12 institutions charged for providing 16 nondistributive pharmacy services. Directors of pharmacy from six hospitals indicated that they billed third party carriers for nondistributive pharmacy services as part of their total pharmacy charge via their usual billing procedure. All third party carriers billed in this manner paid for the nondistributive pharmacy service.

California↗
PubMedDate not supplied

Impact of a limited fluoroquinolone reimbursement policy on antimicrobial prescription claims.

OBJECTIVE: To examine the influence on administrative pharmacy claims of a policy that limited the reimbursement of the fluoroquinolones and other antimicrobials in the senior population within Nova Scotia, Canada. METHODS: The administrative claims database of the Nova Scotia Seniors' Pharmacare Program was used to identify all prescription claims for orally administered antibiotics and urinary antiinfectives. The number of beneficiaries receiving antimicrobials and the number, duration, and cost of prescriptions for antimicrobials were measured monthly. Descriptive time-series plots were used to compare antimicrobial use for two 12-month periods before the institution of the policy (December 1, 1994-November 30, 1995, and December 1, 1995-November 30, 1996) and the 12 months after the policy took effect (January 1, 1997-December 31, 1997). RESULTS: Following the implementation of the fluoroquinolone reimbursement policy, the number of patients using antimicrobials decreased by 2.2% and the number of prescriptions for antimicrobials decreased by 3.4%. Fluoroquinolone prescriptions decreased by 80.2%; prescriptions for sulfonamides and trimethoprim increased by 34.9%, cephalosporins by 17.0%, and macrolides and lincosamides by 16.5%. The only prescription duration to change was the fluoroquinolones, which increased by 25%. The average cost per antimicrobial user/year decreased from $35.24 during prepolicy period 2 to $27.51 during the postpolicy period. CONCLUSIONS: Prescription claims for fluoroquinolones in seniors decreased following the introduction of the policy. Total antimicrobial use also decreased, although this may be related to other factors. The effect of this policy change on patient outcomes requires further study.

Aged↗
PubMed2003

A role for two-stage pharmacoeconomic appraisal? Is there a role for interim approval of a drug for reimbursement based on modelling studies with subsequent full approval using phase III data?

Healthcare decision makers and pharmaceutical companies are increasingly using techniques of economic evaluation, particularly modelling, to assist them in their decisions about drug purchasing and drug development. The use of models in other types of policy decisions is also well established. One option, to shorten the time to a purchasing decision, would be for an interim decision for approval for reimbursement to be based on an economic model. Such a system would mainly benefit the drug development process and thus the pharmaceutical industry; however the approach could also lead to poor decision making, unethical marketing and withdrawal of drugs from the consumer. In this article, we consider the option of a two-stage economic appraisal process from the point of view of the seller, the purchaser and the patient and public. Although a two-stage process may offer some advantages in terms of early return on investment and access, there are significant disadvantages in terms of certainty about effects and public policy and expenditure. Until there are better methods of predicting the effectiveness of a new product, it is unlikely that interim decisions can be seen as a reasonable health policy alternative, although it seems likely that industry may continue to lobby for such an approach.

Australia↗
PubMed2000

Pharmaceutical expenditure in Spain: cost and control.

In recent years, the Spanish government has been battling to keep pharmaceutical expenditures under control. Its measures include control of prices, introduction of a "negative list" of drugs no longer reimbursed, increased cost-sharing, and introduction of overall budgets for pharmaceutical expenditures. Although the average prices of old pharmaceutical products declined by 39 percent over the last 15 years and consumption in value increased by only 10 percent, real pharmaceutical expenditures in Spain increased by 264 percent over that period. The main reason for the continuing rise in these expenditures and the failure of cost-containment measures is the introduction of new, more expensive drugs, which often fail to offer any real therapeutic advantages over products already on the market. This situation is exacerbated by a lack of effective demand-side measures such as budgets for doctors and lack of a generics market.

Cost Control↗
PubMed1986

Comment on Kartell v. Blue Shield of Massachusetts, Inc.: an antitrust analysis of Blue Shield's reimbursement schemes.

In Kartell v. Blue Shield of Massachusetts, Inc., the First Circuit held that Blue Shield's reimbursement practice known as the "ban on balance billing" did not constitute an unlawful restraint of trade in violation of the antitrust laws. Underlying the First Circuit's decision was deference to what it viewed as efforts by Blue Shield and by the Commonwealth to promote cost containment. This Comment argues that, to the contrary, under an appropriate analysis of antitrust law, the practices employed by Blue Shield did constitute unreasonable restraints of trade on the physicians' service industry in Massachusetts, given Blue Shield's market dominance in the Commonwealth. The Comment also argues that such inhibition of the competitive functioning of this industry is unwise, and that costs should instead be contained by effectuating the antitrust laws and encouraging the development of competitive forces within this industry.

Blue Cross Blue Shield Insurance Plans↗
PubMed1984

Cross-subsidies and payment for hospital care.

This study uses hospital data from the 1979 American Hospital Association Reimbursement Survey in a multivariate framework to assess the impact of discounts and third-party reimbursement on hospital costs and profitability. Three central issues are addressed: (1) Is a differential payment justified for Medicare, Medicaid, and/or Blue Cross on the basis of differential costs? (2) Have the cost-containment efforts of the dominant payers reduced total payments to hospitals? and (3) What part of the overall savings in payments to hospitals is in the form of reduced costs rather than reduced profits? On the basis of the evidence in this study, we find (1) that the differential payment is not justified; (2) that the cost-containment efforts of the dominant payers have reduced total payments to hospitals somewhat, but a substantial amount of cost-shifting remains; and (3) that the savings is in profits, rather than in costs.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Billing third party payers for pharmaceutical care services.

OBJECTIVE: To describe the steps pharmacists must complete when seeking compensation from third party payers for pharmaceutical care services. DATA SOURCES: Government publications; professional publications, including manuals and newsletters; authors' personal experience. DATA SYNTHESIS: Pharmacists in increasing numbers are meeting with success in getting reimbursed by third party payers for patient care activities. However, many pharmacists remain reluctant to seek compensation because they do not understand the steps involved. Preparatory steps include obtaining a provider/supplier number, procuring appropriate claim forms, developing data collection and documentation systems, establishing professional fees, creating a marketing plan, and developing an accounting system. To bill for specific patient care services, pharmacists need to collect the patient's insurance information, obtain a statement of medical necessity from the patient's physician, complete the appropriate claim form accurately, and submit the claim with supporting documentation to the insurer. Although many claims from pharmacists are rejected initially, pharmacists who work with third party payers to understand the reasons for denial of payment often receive compensation when claims are resubmitted. CONCLUSION: Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

[Cost analysis of procedural fee for percutaneous transluminal coronary angioplasty at six Japanese hospitals].

BACKGROUND: Disease-specific cost analysis is rarely performed in Japan, but is essential for reform of the healthcare reimbursement system and assessment of procedural fees. METHODS: The actual cost associated with the procedural fee of the percutaneous transluminal coronary angioplasty (PTCA) procedure was estimated by dividing into four categories: labor, disposable materials, expenses, and equipment costs. The special cost associated with PTCA devices such as angioplasty balloon and stent was responsible for the majority of PTCA-related hospitalization costs, but was not included in our survey. The six institutions that participated in the survey belong to the national, Red Cross, and Saiseikai organizations. Time study for labor was omitted, and procedural time was predetermined at 3 hours. RESULTS: The labor cost amounted to yen 65,000 to yen 98,000/procedure. To calculate the cost of disposable materials across all six hospitals, a universal amount of yen 60,000 from a model hospital was used. The expenses ranged from yen 1,000 to yen 39,000, and the expenditure plus capital cost from yen 95,000 to yen 224,000, showing significant differences between the hospitals. The total mean cost was yen 294,000 +/- 55,000, which indicated that every hospital was in deficit. CONCLUSIONS: Compared to Medicare in the United States of America, the procedural fee for Japanese physicians is extremely low, in contrast to the bloated special cost for devices, which causes significant pricing gaps between Japan and USA. The differences in total cost among the hospitals were mainly derived from the cost for angiographic equipment. Our survey did not include any private hospitals, but the PTCA-related procedural fee is less than the actual cost under the current health insurance reimbursement scheme at all hospitals.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Negotiating with third party payers: one community pharmacy's experience.

OBJECTIVES: To evaluate financial terms and legal wording in insurance contracts and negotiate their terms with companies to improve an independent pharmacy's financial position and to determine the time required to negotiate a contract and translate that time into a salary cost. SETTING: An independent pharmacy in a small town in Alabama with a population of approximately 6,000. PRACTICE DESCRIPTION: The prescription department accounts for two-thirds of the pharmacy's sales and dispenses approximately 70,000 prescriptions each year. Insurance companies paid for over 59% of these prescriptions in 2000. The pharmacy is open 7 days a week with one full-time pharmacist and a second pharmacist who works 2 days a month. PRACTICE INNOVATION: A contract negotiation form was developed that addressed factors that might affect a pharmacy's decision to accept or reject a contract; the form included an area for recording the time involved in negotiating each contract. INTERVENTIONS: Insurance companies selected by the pharmacy owner were faxed copies of an Insurer Demographics Collection Form. Upon collection of all data and finalization of proposed changes, a copy of the contract with the proposed changes marked, along with a letter explaining and justifying the changes, was sent to the insurance company. If no response was received from the company, the contact person was called and negotiations proceeded over the telephone. MAIN OUTCOME MEASURES: Primary end points were the percentage of companies that would negotiate and the average increase in reimbursement achieved. Secondary end points included the time involved in negotiations and the translation of that time into a salary cost. RESULTS: None of the nine participating companies accepted any of the changes proposed. The time to negotiate each contract ranged from 28 minutes to 74 minutes, taking an average of 48.4 minutes. Depending on the division of work between the pharmacist and the technician, the salary cost for the negotiations ranged from $14.68 to $18.73 per contract. CONCLUSION: This study provides a realistic description of attempts at contract negotiation between one pharmacy and nine third party payers. The difficulty of achieving successful results and the necessity of carefully considering the time and cost of contract negotiations underscore how important it is for independent pharmacists to concentrate their efforts on contracts and terms they have an opportunity to change.

Alabama↗
PubMed2005

The skill mix practice model for nursing: measuring outcome.

AIM: This paper reports a study examining the outcome of personnel costs and quality of care after implementing the skill mix practice model for nursing. BACKGROUND: In response to ever-tightening government budgets and changes in health insurance reimbursement, it may be necessary for hospitals to reassess their practice models to remain competitive and maintain quality of care. METHOD: Using a pre- and post-test quasi-experimental design with questionnaires, participants were recruited at a teaching hospital in Taiwan. Questions were included on both patient satisfaction with nursing care and nurse satisfaction with nursing aides. The data were collected in 2003. RESULTS: The cost of implementing the skill mix practice model with 22 nurses and seven nursing aides was 2.7% lower than when only using 25 nurses. In addition, there was a statistically significant difference in patient satisfaction and in nurse satisfaction with the performance of the aides. There was no statistically significant difference in the pre- and post-test outcome measures of both the incidence of falls and the medication error rate. CONCLUSION: To decrease costs and increase quality of care, the skill mix practice model is worthy of consideration for clinical nursing care. This study presents an investigation of the first hospital implementation of the skill mix practice model for nursing in Taiwan, and the results of which can serve as a reference model for hospital nursing practice reform.

Attitude of Health Personnel↗
PubMed1980

Pharmacists' views of an experience in capitation reimbursement under the Iowa Medicaid drug program.

The Iowa Medicaid Drug Program recently performed a 2-year experiment in capitation reimbursement of pharmacies in two counties. The aim was to reduce costs and improve the quality of services by creating new economic incentives for pharmacists to expand their role in drug use control. This study is part of an evaluation of this experiment. It summarizes the responses to personal interviews held with the owners or managers of the 11 participating pharmacies and with four employee pharmacists. Almost all pharmacists considered capitation a big improvement over the traditional fee-for-service system of Medicaid payment. The benefit most commonly cites was the advance payment system that some respondents said reduced paperwork and improved their cash flow. Value was also seen in requiring Medicaid patients to designate and obtain services from a single pharmacy, but the pharmacists complained about lack of accurate lists of eligible patients and described wide variations in enforcement of the lock-in. Diversity also appeared in their discussion of problems encountered in making product substitutions. Deficiencies in comprehension and motivation were found to be especially prevalent among the salaried employees.

Attitude of Health Personnel↗
PubMed2005

Analysis of a pharmaceutical risk sharing agreement based on the purchaser's total budget.

Many public and private healthcare payers use formularies as a tool for controlling drug costs and quality. Although the price per dose is often negotiated as part of the formulary listing, payers may still face unlimited financial risk if demand is much greater than expected at the time of listing. The requirement for drug manufacturers to submit a budget impact analysis as part of the drug approval process suggests that payers are concerned not only with the cost effectiveness of a proposed drug but also with the potential increase in total expenditures that may result from new formulary listings. In this paper we define and analyze a model for financial risk sharing based on the total budget. Our analysis focuses on optimal decision making by manufacturers in the presence of a specific risk sharing agreement. We derive a manufacturer's optimal statement of budget impact and discuss several properties of the optimal solution.

Cost-Benefit Analysis↗