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PubMed2005

Reshuffling the DRG deck. New cardiac DRGs praised for more equitable reimbursements while post-acute-transfer changes are generating some worries.

The CMS' changes to its DRGs, which took effect Oct. 1, could alter hospitals' bottom lines significantly. The addition of 16 DRGs makes a total of 526 classifications that will dictate payments and determine hospital services and patient mix. Tom Watson, left, a partner with accounting firm BKD, which specializes in healthcare reimbursement, says it's unlikely the changes will put any hospitals out of business, but they will feel a pinch.

Aged↗
PubMed2006

Nails and numbers.

Explore the source record for details and available documents.

Healthcare Common Procedure Coding System↗
PubMed1998

Galen-In-Use: using artificial intelligence terminology tools to improve the linguistic coherence of a national coding system for surgical procedures.

GALEN has developed a language independent common reference model based on a medically oriented ontology and practical tools and techniques for managing healthcare terminology including natural language processing. GALEN-IN-USE is the current phase which applied the modelling and the tools to the development or the updating of coding systems for surgical procedures in different national coding centers co-operating within the European Federation of Coding Centre (EFCC) to create a language independent knowledge repository for multicultural Europe. We used an integrated set of artificial intelligence terminology tools named CLAssification Manager workbench to process French professional medical language rubrics into intermediate dissections and to the Grail reference ontology model representation. From this language independent concept model representation we generate controlled French natural language. The French national coding centre is then able to retrieve the initial professional rubrics with different categories of concepts, to compare the professional language proposed by expert clinicians to the French generated controlled vocabulary and to finalize the linguistic labels of the coding system in relation with the meanings of the conceptual system structure.

Artificial Intelligence↗
PubMed1997

Galen-In-Use: an EU Project applied to the development of a new national coding system for surgical procedures: NCAM.

GALEN has developed a language independent common reference model based on a medically oriented ontology and practical tools and techniques for managing healthcare terminology including natural language processing. GALEN-IN-USE is the current phase which applied the modelling and the tools to the development or the updating of coding systems for surgical procedures in different national coding centre co-operating within the European Federation of Coding Centre (EFCC) to create a multilingual knowledge repository for multicultural Europe. NCAM (Nomenclature Commune des Actes Médicaux) is the new French multipurpose coding system for surgical procedures. The labels are processed from the intermediate dissections to the Grail representation and the natural language generation by the electronically related Medical Informatics research centres network of Saint Etienne, Manchester, Geneva and Nijmegen. The national coding centre is able to retrieve the initial labels with different categories of concepts, to compare the professional language proposed by expert clinicians to the French generated controlled vocabulary and to finalize the linguistic labels of the coding system in relation with the meanings of the conceptual system structure.

Electronic Data Processing↗
PubMed1999

Payer cost savings with endometrial ablation therapy.

CONTEXT: Dysfunctional uterine bleeding (DUB) is a significant cost burden for payers in the US healthcare system because hysterectomy, the common curative treatment, is associated with high hospitalization costs. OBJECTIVE: To determine the potential economic benefit to payers of endometrial ablation as an alternate treatment for the benign DUB disorder. STUDY DESIGN: A retrospective analysis of healthcare claims including the total direct costs to the payer (reimbursement) and patient (copayment). The study was designed to capture all DUB-related claims costs for the entire episode of care from initial diagnosis through follow-up care for 12 months postprocedure. PATIENTS AND METHODS: Twenty-four months of claims data from premenopausal women aged 25 to 50 years enrolled in a large managed care organization were screened based on relevant diagnostic and procedural codes. Incidence and costs of hysterectomy and ablation were determined, and potential payer savings were calculated based on hypothetical hysterectomy-to-ablation conversion rates of 25% to 50%. RESULTS: By performing ablation in lieu of hysterectomy for DUB, an average per-case savings of approximately $4,300 is possible. Potential annual payer savings are approximately $515,000 and $1.03 million for a 1-million-member plan, based on the 25% and 50% conversion rates, respectively. The recently approved uterine balloon therapy ablation technique could be instrumental in overcoming current barriers to wider utilization of ablation surgery. CONCLUSION: If ablation is used in lieu of hysterectomy when medically appropriate, a payer organization could reduce the cost of treating patients with DUB who are not responsive to drug therapy or dilation and curettage alone. Our data suggest that hysterectomy is the most common surgical therapy for this disorder, even though the less invasive endometrial ablation approach is more consistent with accepted DUB treatment guidelines. Payers therefore have an economic incentive to adopt guidelines and reimbursement policies that promote ablation therapy for DUB.

Adult↗
PubMed2001

Diabetes mellitus in managed care: complications and resource utilization.

OBJECTIVES: To implement a diabetes mellitus surveillance system designed to use administrative data and to demonstrate how it can be used by managed care organizations (MCOs) with different administrative data systems to estimate the prevalence of diabetic complications and describe utilization of services in persons with and without complications and comorbidities. STUDY DESIGN, PATIENTS, AND METHODS: We identified individuals with diabetes mellitus in 3 MCOs in 1993 using 4 sources of computerized data records: inpatient, pharmacy, outpatient, and laboratory. The presence of diabetes mellitus complications and cardiovascular comorbidities were determined using diagnostic and procedural codes. Use of healthcare resources by persons with and without complications and comorbidities was determined from computerized administrative data. RESULTS: The most prevalent complication or comorbidity was cardiovascular disease (45%-53%), followed by eye disease (20%-34%), lower extremity disease (8%-20%), and renal disease (3%-6%). The presence of multiple complications was common and ranged from 14% to 34% in the 3 MCO populations. Compared with persons with none, persons with 2 or more complications or comorbidities used moderately more primary care services (1.3-1.9 times more) and markedly more specialty care services (5.8-6.3 times more), emergency department visits (3.3-5.5 times more), and hospitals stays (3.3-11.9 times more). CONCLUSIONS: Diabetic complications were common and had a large impact on patients' use of healthcare services. Within MCOs, administrative databases are useful tools for estimating and monitoring the prevalence of diabetic complications and the use of healthcare resources associated with these complications.

Comorbidity↗
PubMed1998

The cost of inpatient endometriosis treatment: an analysis based on the Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

OBJECTIVE: To determine the prevalence and cost of endometriosis-related hospitalizations based on the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP-3). STUDY DESIGN: Retrospective analysis based on nationwide clinical practice data. PATIENTS AND METHODS: Data were obtained for 1991 and 1992 from the HCUP-NIS database, which was a 20% sample of all US hospital discharges. ICD-9 codes (236.0, 617.0 to 617.9) were used to identify females, aged 15 to 54, with endometriosis as a diagnosis. The distribution of endometriosis admissions by admission type, length of stay (LOS), mean total charge, specific types of endometriosis, principal procedures, and other diagnosed diseases was described. RESULTS: In 1991 and 1992, 37,273 (22.6/1000) and 38,834 (23.7/1000) hospital admissions, respectively, were for endometriosis (as any diagnosis). The average LOS and total hospital charges for endometriosis as the primary diagnosis were 3.8 days and $6,597 for 1991, and 3.5 days and $7,450 for 1992. Most endometriosis admissions occurred in females aged 35 to 49. About 87% of the endometriosis hospitalizations were routine admissions. The most common diagnosis was endometriosis of the uterus (51%); the most common procedure was a total abdominal hysterectomy (55%-60%). Older and African-American patients had the longest LOS and the highest total charges. The estimated total hospitalization costs, as represented by hospital charges, for women with endometriosis as the primary diagnosis in the United States were $504 million for 1991 and $579 million for 1992. CONCLUSION: Endometriosis-related hospitalization is a major burden on healthcare systems.

Adolescent↗
PubMed1999

Hospitalization costs associated with leiomyoma.

The objective of this study was to determine the prevalence and cost of leiomyoma-related hospitalizations based on the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP-3). Data for 1991 and 1992 were obtained from the HCUP-NIS database, which includes an approximate 20% sample of US hospital discharges. ICD-9 (International Classification of Diseases, Ninth Revision) codes 218.0-218.2 and 218.9 were used to identify women between the ages of 15 and 64 years with the diagnosis of leiomyoma. The distribution of leiomyoma was described using demographic characteristics, admission type, length of stay (LOS), mean total charge, specific leiomyoma diagnosis, principal procedure, and other diagnosed diseases. Among hospital admissions of women between the ages of 15 and 64 years during 1991 and 1992, 26 to 28 admissions per 1000 included a diagnosis of leiomyoma. The highest rates of leiomyoma diagnosis were seen in women aged >40 years (65% and 70% for 1991 and 1992, respectively) and black women (26% and 27%, respectively). Approximately 90% of hospitalizations for leiomyoma were routine admissions, with the most common specific diagnosis being intramural leiomyoma of the uterus. In 1992, patients with leiomyoma as the first diagnosis (vs other diagnoses) had significantly lower mean LOS (3.1 vs. 4.4 days; P<0.001) and mean total charge ($5919 vs. $6810; P<0.001). Total abdominal hysterectomy was performed on three quarters of the women admitted for leiomyoma, and these patients had longer mean LOS and higher total charges than those undergoing other procedures. Although not as costly as other conditions, this common disorder among women of reproductive years requires expensive treatment and is a major burden on the health care system.

Adolescent↗