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PubMed1998

Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships--HCFA. Proposed rule.

This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: Clinical laboratory services. Physical therapy services. Occupational therapy services. Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. Radiation therapy services and supplies. Durable medical equipment and supplies. Parenteral and enteral nutrients, equipment, and supplies. Prosthetics, orthotics, and prosthetic devices and supplies. Home health services. Outpatient prescription drugs. Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the law. The proposed rule is based on the provisions of section 1903(s) and section 1877 of the Social Security Act, as amended by section 13562 of the Omnibus Budget Reconciliation Act of 1993, and by section 152 of the Social Security Act Amendments of 1994.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1987

The marketing of partial hospitalization.

Health-care professionals are currently operating in the context of a rapidly changing health-care delivery system, including the move away from inpatient services to outpatient services in order to control costs. Those who practice in partial-hospital settings are in a position to offer effective, cost-efficient services; however, there continue to be obstacles which hinder appropriate utilization of the modality. The development and use of a well-designed marketing plan is one strategy for removing these obstacles. This paper presents a brief overview of the marketing process, ideas for developing a marketing plan, and several examples of specific marketing strategies as well as ways to monitor their effectiveness. Partial-hospital providers must take an active role in answering the calls for alternative sources of psychiatric care. A comprehensive, education-oriented marketing approach will increase the public's awareness of such alternatives and enable programs to survive in a competitive environment.

Adolescent↗
PubMed1983

Summary of the 1983 annual reports of the Medicare Board of Trustees.

This summary presents an overview of the information contained in the annual reports of the trustees required under Title XVIII of the Social Security Act, Health Insurance for the Aged and Disabled, commonly known as Medicare. There are two basic programs under Medicare: Hospital insurance (HI), which pays for inpatient hospital care and other related care of those 65 years of age and over and of the long-term disabled. Supplementary medical insurance (SMI), which pays for physicians' services, outpatient hospital services, and other medical expenses of those 65 years of age and over and of the long-term disabled. The HI program is financed primarily by payroll taxes, with the taxes paid by current workers used to pay benefits to current beneficiaries. However, the HI program maintains a trust fund that provides a small reserve against fluctuations. This type of financing is generally known as pay-as-you-go financing. By contrast, the SMI program is financed on an accrual basis with a contingency margin. This means that the SMI trust fund should always be somewhat greater than the claims that have been incurred by enrollees but not yet paid by the program.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed2001

Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments concerning the ownership and investment exceptions in paragraphs (c) and (d) and the compensation exceptions in paragraph (e) of section 1877 of the Act. Phase II of this rulemaking will also address comments concerning the reporting requirements and sanctions provided by paragraphs (f) and (g) of the Act, respectively, and include further consideration of the general exception to the referral prohibition related to both ownership/investment and compensation for services furnished in an ambulatory surgical center (ASC), end-stage renal dialysis facility, or by a hospice in section 411.355(d) of the regulations (this exception presently is in force and effect as to clinical laboratory services). In addition, Phase II of this rulemaking will address section 1903(s) of the Act, which extends aspects of the referral prohibition to the Medicaid Program. Phase II will also address comments received in response to this rulemaking, as appropriate, and certain proposals for new exceptions to section 1877 of the Act not included in the 1998 proposed rulemaking, but suggested in the public comments.

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

Medical care expenditures under gatekeeper and point-of-service arrangements.

OBJECTIVE: To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network. DATA SOURCE/STUDY SETTING: The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services. STUDY DESIGN: Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables. PRINCIPAL FINDINGS: Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses. CONCLUSIONS: Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Adolescent↗
PubMedDate not supplied

Sex differentials in health.

Health status and health behavior of males and females in the United States are compared; the data employed in the analysis are from community studies and the surveys of the National Center for Health Statistics. Females generally show a higher incidence of acute conditions, higher prevalence of minor chronic conditions, more short-term restricted activity, and more use of health services (especially outpatient services) and medicines. By contrast, males have higher prevalence rates for life-threatening chronic conditions, higher incidence of injuries, more long-term disability, and after about age 50, higher rates of hospitalization. These sex differences appear at all ages, except for early childhood when boys have a worse health profile than girls. The following interpretations are consistent with the data; they are hypotheses rather than demonstrated facts. Women are more frequently ill than men, but with relatively mild problems. By contrast, men feel ill less often, but their illnesses and injuries are more serious. These morbidity differences help to explain sex differentials in health behavior; frequent symptoms lead to more restricted activity, physician and dentist visits, and drug use for women; severe symptoms lead to more permanent limitations and hospitalization for men. But attitudes about symptoms, medical care, drugs, and self-care are also extremely important. Males may be socialized to ignore physical discomforts; thus, they are unaware of symptoms that females feel keenly. Also, men may be less willing and able to seek medical care for perceived symptoms. When diagnosis and treatment are finally obtained, men's conditions are probably more advanced and less amenable to control. Finally, men may be less willing and able to restrict their activities when ill or injured. Four important factors than underlie sex differentials in health are discussed: inherited risks of illness, acquired risks of illness and injury, illness and prevention orientations, and health reporting behavior. Statistics show that women ultimately have lower mortality rates than men--despite women's more frequent morbidity and possibly because of more care for their illnesses and injuries. The apparent contradiction between sex differences in morbidity and mortality (females are sicker but males die sooner) is explored.

Acute Disease↗
PubMed1997

A tale of two New Jersey cities.

Judging from the social and health measures considered in this article, Newark and Jersey City face similar challenges as other large cities. For Newark, the challenges are more extreme. The high rates of poverty and violence, coupled with a low rate of high school graduation and a large number of single parent households bode ill for the city. The hospitals in Newark and Jersey City have undergone major changes in meeting the needs of their communities. They have adjusted their size, shortened their lengths of stay, and provided more intensive care services and outpatient services. Of special concern for New Jersey's hospitals is the reliance on Medicaid financing. If dramatic changes are made to the Medicaid program, Newark hospitals should be on high alert. Legislatures need to tread carefully in designing policies that address the needs of New Jersey's large cities. The state is undergoing major changes in its health care system. The demise of the all-payer rate setting system, the establishment of the Health Care Subsidy Fund to finance uncompensated care and subsidize insurance for low and middle-income families, modifications to the community rating system for private insurance, and changes to the welfare system that affect eligibility for Medicaid all require legislators to consider the context in which these programs operate.

Adolescent↗
PubMed2005

[Quality assurance of outpatient nursing services in Baden-Württemberg -- overall view of 6 years of a total survey by the Medical Services of the Statutory Health Insurance (MDK)].

During the years 1997 to 2003 the medical services of the statutory health insurance in the German Federal State of Baden-Württemberg carried out a total survey regarding structure, process and outcome with regard to the quality of care of outpatients in the German long-term care insurance system. This survey provides information on the development of the quality of care. All outpatient nursing services licensed by the statutory long-term care insurance funds in Baden-Württemberg (n (1997 - 2000) = 863; n (2000 - 2003) = 779) were subjected to a uniform assessment based on a consented concept applied in all German Federal States. Our results demonstrate a tendency to fewer but larger nursing services providing care for an increasing number of patients. Qualification of head nurses and of caregiving staff in general has significantly improved. Information for the patient/consumer on the conditions of contracts which have to be made between a nursing service and the patient is still deficient in more than 20 % of cases. Adherence to proper procedures in the process of nursing has improved, especially with respect to taking a complete medical/nursing history and defining the individual resources of a patient and aims for therapy/nursing. However, only in (1/3) of the cases could we find a documentation of continuous adaptation of the planning of therapy. Efforts of in-house quality management and internal quality assurance by the outpatient nursing services have improved. Regarding the outcome of nursing there has been a decrease in the provision of stimulating care from 87 % of cases to 75 %. The majority of patients of outpatient nursing services do not receive benefits of the long-term care insurance system but of the statutory health insurance. This fact underlines the importance of a general conceptual framework for internal and external quality assurance.

Ambulatory Care↗
PubMed1998

Initiating clozapine treatment in the outpatient clinic: service utilization and cost trends.

OBJECTIVE: Clozapine has been shown to be a cost-effective treatment for refractory psychosis among patients started on the medication in a hospital setting. The study examined service utilization and costs associated with clozapine treatment initiated in an outpatient clinic. METHODS: Subjects (N=28) included adult patients with a diagnosis of schizophrenia or schizoaffective disorder who began their clozapine treatment at an urban community mental health center. Subjects' charts were reviewed for information on service utilization in the year before and after starting clozapine, using an intent-to-treat approach. Hospitalization information was cross-checked against the Illinois Department of Human Services database. Costs were computed for hospitalization, medication, community outpatient services, and housing. RESULTS: Subjects' mean rate of hospitalization was reduced by more than half during the clozapine treatment year, and the mean number of days in the hospital decreased by more than two-thirds, from 23.5 days to 7.6 days. Mean hospitalization costs were reduced by more than half. Mean annual costs of medication rose from $648 in the year before clozapine treatment to $6,760 during the clozapine treatment year. Cost increases for medication, community services, and housing led to a marginal increase in the total cost of treatment. CONCLUSIONS: Patients initiating clozapine treatment on an outpatient basis showed a pattern of decreased hospitalization during the first year on clozapine. The cost savings associated with decreased hospitalization substantially, though not fully, offset the increased expense of clozapine during the first year of community-based treatment.

Adult↗
PubMed1999

On-site primary care and mental health services in outpatient drug abuse treatment units.

Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.

Adolescent↗
PubMed1995

Contracting for outpatient surgical services.

This article provides a review of factors that influence a managed care entity's choice of a provider of outpatient surgical services. In reviewing issues, this article also provides practical guidance to the outpatient surgery center with respect to the pricing and marketing of its services. Finally, the article provides an overview of both business and legal issues relating to managed care contracting choices.

Contract Services↗
PubMed1992

The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups.

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Adult↗
PubMedDate not supplied

Impact of HIV risk and infection on delivery of psychosocial treatment services in outpatient programs.

HIV risk and HIV infection have profoundly affected the delivery of psychosocial treatment services in outpatient drug treatment settings. First, HIV has changed the programmatic emphasis of outpatient treatment, from the intake process through the goals of care, and treatment program staff are being altered significantly. Second, HIV brings with it a pull to extend the reach of drug abuse treatment to the sexual partners and families of patients. Finally, for community and statewide planners, a debate is emerging between the idea that programs should provide high-quality services to a few targeted "high risk" or "vital category" patients versus providing minimal services to as many drug abusers as possible. There is a vital need for research studies that will add data to the decision-making process, at both the policy and programmatic levels.

Ambulatory Care↗