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At least 253 records · Page 14Linked to original sources
PubMed1984

Hospital cost shifting.

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Blue Cross Blue Shield Insurance Plans↗
PubMed1995

Potential effects of managed care on specialty practice at a university medical center.

BACKGROUND: The growth of managed care presents a challenge to academic medical centers, because the demand for the services of specialists is likely to continue decreasing. We estimated the number of enrollees the University of Michigan Medical Center would need in its health maintenance organization (HMO) system in order to provide revenue equivalent to the total revenue it received for professional specialty care in 1992. METHODS: Rates of utilization and payment were based on the medical center's experience with managed care in 1992 in its independent practice association HMO, in which 25,000 members had capitated coverage and received primary and all specialty care from university physicians, and 15,000 members received primary care and most specialty care from physicians outside the university. We assumed that persons not enrolled in Medicare were all enrolled in managed-care plans. Primary care activity was excluded from the calculations of expense, revenue, and numbers of faculty members. RESULTS: If all specialty services were provided by the university to HMO members, all the 21 specialties examined except obstetrics and gynecology and emergency services would require an enrollment of more than 250,000 to support the 1992 level of professional revenue and maintain the number of faculty members. If university services were provided only for referrals from a loosely affiliated network of community physicians in the HMO system, all the 19 specialties examined except plastic surgery would require an HMO enrollment of more than 1 million. In a combined model in which all specialty services were provided to 100,000 HMO members and network referrals were provided to 500,000 members, substantial changes in faculty composition would be needed in all the departments studied. CONCLUSIONS: Because of the large number of HMO members required, unless other changes occur, it is unrealistic to expect that the University of Michigan Medical Center could create an HMO or network large enough to support the specialty practice of the current number of faculty members at the 1992 level of financing.

Academic Medical Centers↗
PubMedDate not supplied

A home care update.

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Accreditation↗
PubMed1995

The response of the dominant firm to competition: the Ocean State case.

The Ocean State antitrust case illustrates the operation of the competitive marketplace in health insurance. Blue Cross, the dominant firm in Rhode Island, responded competitively to the entrance of a new competitor, Ocean State, in three ways: 1) a most-favored-nation clause, 2) creation of a PPO offering similar benefits as Ocean State, and 3) an adverse selection policy. These actions are assessed to be legitimate competitive responses and the decisions of the higher courts overturning the jury verdict against Blue Cross are supported.

Antitrust Laws↗
PubMed1979

Carrier discretionary practices and physician payment under Medicare Part B: a preliminary report.

Although Medicare is a national program, administration of Part B payments to physicians is in the hands of insurance organizations in ten Medicare regions. The carriers follow varying practices in using actual charges within localities as the basis for determining reasonable charges for physicians' services. While some of these practices have already been shown to influence fee levels, reasonable charge determination involves many more whose influence has not been systematically studied. This paper reviews preliminary findings from a study which examines carrier differences in discretionary practices as to specialties, localities and other claims data that may be merged or compared with Medicare data in determining customary and prevailing prices used to set limits on Medicare payments, and other practices reported in an official questionnaire to carriers. The effect on fee levels and other measures of program performance is being studied after taking into account social, economic and health resource variables extracted from the Area Resource File, that are expected to influence local medical prices through the demand for and supply of physicians' services. Dependent variables representing fees are the 50th percentile of the distribution of weighted customary charges of individual physicians in an area and Supplementary Medical Insurance expenditure per enrollee. The preliminary findings in this paper concern discretionary practices, socioeconomic variables and fee distributions.

Decision Making↗
PubMed1984

Hospice home care cost savings to third-party insurers.

A population-based, retrospective analysis of Medicare Part A and Blue Cross hospital insurance claims data was used to determine whether hospice home care cost savings to third-party insurers are substantial and result from the substitution of less expensive home care visits for more costly hospital inpatient days. The study was carried out by comparing the third-party payments of Cuyahoga County residents who died of cancer and were served by a hospice home care program (n = 152) with the insurance payments of cancer patients who never received hospice home care (n = 1,397). The data strongly supported the research hypothesis. The relative use of hospital days decreased more than 50% and the use of home care visits increased 10-fold when dying patients shifted from conventional care to hospice home care. This change in use represented a relative savings of about 40%, ranging from $1,089 per patient during the last 2 weeks of life to $2,676 per patient during the last 12 weeks of life. These results were not accounted for by group differences in age, type of cancer, or personal preference for home care.

Age Factors↗
PubMed2004

Emergency room coverage: an evolving crisis.

Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.

Cost Control↗
PubMed2004

Tales of greed.

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Ethics, Medical↗
PubMed2004

Glaucoma treatment in Australia: changing patterns of therapy 1994-2003.

AIM: To document the change in pattern of glaucoma treatment in Australia over the decade 1994-2003. METHODS: Observational study: retrospective data audit. RESULTS: The total number of prescriptions for glaucoma items has increased in this time period from 1.9 million to 3.3 million, with a cost increase to the Pharmaceutical Benefits Scheme (PBS) of in excess of 50m dollars. The largest increase has been in the class of prostaglandin analogues, which now comprise 49% of all glaucoma topical therapy prescriptions. Rates of laser trabeculoplasty and trabeculectomy surgery have fallen by 60% and 58%, respectively. Rates for secondary procedures such as repeat trabeculectomy, drainage implant devices and cycloablation have remained stable, although with some variation between Australian states. CONCLUSIONS: The introduction of multiple new medications has resulted in a decline in the amount of glaucoma surgery and laser trabeculoplasty performed. There has been an associated increase in the total number of glaucoma prescription items dispensed, and a large increase in the cost to the PBS of this change. Outcome measures of the benefit of these changes are lacking.

Antihypertensive Agents↗