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PubMed1999

Paying a premium: how patient complexity affects costs and profit margins.

OBJECTIVE AND BACKGROUND: Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. MATERIALS AND METHODS: The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. RESULTS: The profit margin on nonsurvivors was $5,898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. CONCLUSIONS: There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors' trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured.

Cost Allocation↗

PubMed1995

Impact of reimbursement systems on child psychiatrists: a comparison of Canada and the United States.

OBJECTIVE: This study measured satisfaction of US and Canadian child psychiatrists with quality of care in their field and behaviors of their payers. METHOD: US and Canadian child psychiatrists were surveyed concerning time spent on billing paperwork, waiting times for psychiatrist reimbursement and patient treatment, and their satisfaction with psychiatric services and behaviors of payers. Initial and two nonresponder follow-up mailings of the survey were sent in 1992 to all 83 Canadian members of the American Academy of Child and Adolescent Psychiatry and a random sample of 212 US members. RESULTS: Canadians were significantly more satisfied than Americans with the quality and affordability of services for both inpatients and outpatients. Canadians were less likely to think that third-party payers were annoying or affected their clinical decision-making. Canadians spent less time on billing-related paperwork and received payment more promptly. Canadians, however, reported significantly longer waits for both inpatients and mildly ill outpatients, but not for severely ill outpatients. CONCLUSIONS: Canadian child psychiatrists were significantly more satisfied with the quality of psychiatric services and the behaviors of their payers, but Canadian patients experienced longer waits.

Canada↗

PubMed2001

Patient-initiated second medical opinions: their necessity and economic cost.

PURPOSE: To assess the value of patient-initiated second medical opinions (SMO). METHODS: The authors prospectively collected demographic data from 100 consecutive patients. The authors recorded major changes in the patients' care, such as inappropriate surgery recommended, inadequate treatment performed, and appropriate treatment not recommended. The authors also recorded costs incurred or saved by the patients and the third-party payers. RESULTS: In nearly 15 of the cases, the authors had major disagreements with the initial diagnosis or management. Surgery had been recommended in 28 cases. They advised against it in nine. In 72 cases, no surgery had been recommended. They advised and performed it in five. The management of five other patients was not in accordance with that recommended by large clinical trials or was inadequately done. Including the consultation fees, surgery performed or advised against, retinal angiography, and ultrasonography, the 100 SMO cost third-party payers $12,426. If the authors subtract the cost of noncontroversial surgery they recommended and if the patients had paid the consultation fee and had brought along their fluorescein angiograms, third-party payers would have saved $4,079. CONCLUSION: The savings SMO generated by eliminating unnecessary surgery resulted in improved patient care at minimal cost to third-party payers.

Adolescent↗

PubMedDate not supplied

A pharmacoeconomic analysis of pegaspargase versus native Escherichia coli L-asparaginase for the treatment of children with standard-risk, acute lymphoblastic leukemia: the Children's Cancer Group study (CCG-1962).

PURPOSE: The purpose of this pharmacoeconomic analysis was to compare pegaspargase. a newer chemotherapeutic agent used for treating acute lymphoblastic leukemia, with native Escherichia coli L-asparaginase in induction, delayed intensification 1 and delayed intensification 2. MATERIALS AND METHODS: A subset of patients with newly diagnosed, standard-risk, acute lymphoblastic leukemia enrolled in the Children's Cancer Group (CCG) study CCG-1962 at seven participating institutions gave consent and was enrolled in our pharmacoeconomic analysis study. Societal (transportation, lodging, missed workdays, food, babysitter) and payer (frequency of encounters) cost data were collected from diaries (n = 27). Additional payer costs, such as drug costs, cost per clinic visit, and cost per inpatient day stay were collected from patients in CCG-1962 and participating institutions. We considered costs of therapy, including higher pegaspargase costs when comparing regimens of pegaspargase versus native E. coli L-asparaginase in induction, delayed intensification 1, and delayed intensification 2. RESULTS: Our results showed that the costs of the two therapies were similar from the payer perspective, with pegaspargase costing 1.8% more than E. coli L-asparaginase. The difference between groups also was small (<1%) from the societal perspective. Inpatient stay accounted for 88% of pegaspargase payer costs and 91% of the native E. coli L-asparaginase costs. CONCLUSION: We recommend that pegaspargase not be withheld from treatment protocols solely because of its higher pharmacy costs.

Antineoplastic Agents↗

PubMed2002

Cost-benefit analysis of pediatric cochlear implantation: German experience.

HYPOTHESIS: To explore, from the payers' perspective, the cost-benefit ratio of pediatric cochlear implantation for congenitally deaf and prelingually deafened children compared with children with hearing aids. The study should verify the hypothesis that educational and associated costs increase with age at implantation and that these can be below costs for children with hearing aids. METHODS: Children who received implants at the Medical University of Hanover at different ages (Group 1, 0-1.9 yr; Group 2, 2-3.9 yr; Group 3, 4-6.9 yr) were compared with deaf children using hearing aids (Group 4). Sick funds were the payers for direct and indirect costs, and public authorities were the payers for educational costs. Educational settings were used to measure for benefits. All costs related to the hearing deficiency were included up to the age of 16 years on the basis of 1999 currency values. A scenario analysis was used to explore the impact of variation of costs and discount rates. RESULTS: Total costs for the three age groups of children with implants were from euro 138,000 (approximately US$113,100) to euro 177,000 (approximately US$152,700), compared with euro 160,000 (approximately US$138,000) for hearing aid users. CONCLUSION: This study supports the view that pediatric cochlear implantation provides positive cost-benefit ratios compared with hearing aid users, depending on the age at implantation. Implantation is strongly recommended from the payers' perspective for children implanted before the age of 2 years.

Child↗

PubMed2006

Validity of cancer registry medicaid status against enrollment files: implications for population-based studies of cancer outcomes.

BACKGROUND: Poor access to or inadequate health insurance contributes to disparities in cancer incidence and mortality. Cancer registry "payer source" data is collected by many cancer registries in the United States and has been used to compare cancer outcomes across insurance types. OBJECTIVES: We evaluated the validity of cancer registry data on patient Medicaid status against enrollment data from Medi-Cal, California's Medicaid program. METHODS: Data from the statewide California Cancer Registry for persons under age 65 years diagnosed with 1) any cancer in 1998 and 1999 or 2) with invasive cervical cancer between 1996 and 1999 were obtained and linked probabilistically to Medi-Cal enrollment files. We compared registry Medicaid status, determined from payer source information, against linkage results and used crosstabulations to calculate sensitivity, specificity, and positive predictive value. These measures were compared across different hospital and patient characteristics and cancer types. RESULTS: Cancer registry Medicaid status data had poor sensitivity (48%), good specificity (98%), and moderate positive predictive value (77%). Measures of validity did not vary substantially by cancer type, stage, patient age, sex, vital status, race/ethnicity, socioeconomic status, or diagnosing hospital size. Registry data undercounted the number of Medicaid patients by 52% and incorrectly assigned Medicaid as a payer to approximately 2% of patients. CONCLUSIONS: As a result of the poor validity of cancer registry Medicaid status data, caution should be used when interpreting cancer outcomes by insurance type calculated from registry payer source data. Linkage of registry data to Medicaid enrollment files represents a more accurate means of identifying Medicaid insurance status.

Adolescent↗

PubMed2007

Requests for 692 transfers to an academic level I trauma center: implications of the emergency medical treatment and active labor act.

BACKGROUND: The Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers (TC) to accept all transfers for a higher level of care if capacity exists. We hypothesized that EMTALA would burden a Level I TC by a selective referral of a poor payer mix of primarily nonoperative patients. METHODS: All transfer calls (December 2003 and September 2005) to our Level I TC are handled by a dedicated transfer center. Calls were reviewed for age, surgical service requested, and outcome of request. The trauma registry was queried to compare Injury Severity Scale (ISS) score, hospital stay (LOS), operations, mortality, and payer status for transfer and primary catchment patients. RESULTS: In all, 821 calls were received; 77 calls were cancelled by the referring hospital and 52 were for consultation only. Of the 692 transfer requests, 534 (77%) were accepted, 134 (19%) were denied for no capacity, and only 24 (4%) were declined by TC as not clinically indicated. Transferred patients were younger (32.0 +/- 1.49 versus 38.9 +/- 0.51, p < 0.05), had similar ISS scores (13.6 +/- 0.62 versus 13.7 +/- 0.26) and LOS (7.0 +/- 0.70 versus 7.4 +/- 0.25), but were somewhat more likely to require an operation than direct admissions (58% versus 51%, p < 0.05). Although trauma (24%) and neurosurgery (24%) were the most commonly requested services, followed by orthopedics (20%), orthopedics accounted for 60% of operations on transferred patients compared with 10% to 13% for trauma and neurosurgery (mostly spine). There was no difference in the payer status of transfer and direct admit patients. CONCLUSIONS: Contrary to our assumptions, EMTALA patients had an identical payer mix and similar operative need compared with our primary catchment patients. They do represent a large additional patient load (20% of admissions) and differentially impact specialists, mostly operative for orthopedics and complex nonoperative care for trauma and neurosurgery. These data suggest that the primary motivations for transfer are specialist availability and complexity of care rather than financial concerns. As TCs provide backup specialty call coverage for a wide geographic area, this further supports the need for trauma systems development.

Adult↗

PubMed1995

Who will pay for involuntary civil commitment under capitated managed care? An emerging dilemma.

Involuntary civil commitment in managed care settings may create conflicts between providers and payers. Providers may determine that a patient, particularly one who presents a risk to self or others, must be confined beyond the period reimbursed by the payer. Court decisions have upheld clinicians' ethical obligations to provide care in these situations. In addition, civil commitment may be used to shift costs of long-term care to another provider. The author explores these issues and suggests six strategies that providers can use to address them. They include avoiding negotiations with payers over individual patients' care by ensuring that contracts with payers address civil commitment and patients at risk of harming themselves or others, identifying and creating services and social supports to reduce the necessity for commitment and allowing creative use of benefits, adopting formal risk assessment protocols to standardize the process for all patients and and clinicians, conducting research on the use of civil commitment and coercion in managed care settings, ensuring that incentives do not exist in states' Medicaid managed care programs to use civil commitment to shift costs, and holding discussions with treatment staff about the growing encroachment of financial considerations into treatment decisions.

Adult↗

PubMed1988

PPS waivers: implications for Medicare, Medicaid, and commercial insurers.

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.

Economics, Hospital↗

PubMed2000

Efficacy and cost analysis of ibutilide.

OBJECTIVE: To determine the efficacy and safety of ibutilide in atrial fibrillation (AF) and atrial flutter (AFl) in a clinical setting and to compare the cost of first-line ibutilide with that of projected first-line electrical cardioversion (EC) from a hospital and third-party payer perspective. METHODS: Medical records of all patients (n = 60) who received ibutilide from August 1996 to March 1998 were reviewed. Efficacy was defined as successful conversion to sinus rhythm within 60 minutes of the end of the infusion, and the maintenance of sinus rhythm until hospital discharge. Safety was evaluated by determining the incidence of torsade de pointes. Charges for EC and drug administration were obtained from the hospital database and converted to costs using cost/charge ratios. Hospital costs included drug, drug administration, cardiac intensive care laboratory fee, and the cost of managing torsade de pointes. The third-party payer calculation included all of the above plus the cardiologist and anesthesiologist fees. RESULTS: Fifty percent of patients with AF or AFl were successfully converted with ibutilide; 67% of these remained in sinus rhythm at hospital discharge. Three patients experienced nonsustained torsade de pointes; all resolved with pharmacologic management. From a hospital perspective, the cost of first-line ibutilide was greater than the cost of first-line EC ($280 vs. $138 per patient). However, from a third-party payer perspective, the use of ibutilide saved approximately $324 per patient ($718 vs. $1042). CONCLUSIONS: The efficacy and safety of ibutilide in the clinical setting are consistent with data reported in clinical trials. In contrast to a previous decision analysis, ibutilide was not associated with cost savings from a hospital perspective, but was from a payer perspective.

Aged↗

PubMed2004

Pharmacist compensation for cognitive services: focus on the physician office and community pharmacy.

We provide a stepwise approach for the clinical pharmacy practitioner in the physician clinic or community pharmacy setting to secure compensation for cognitive services. How to establish compensation for pharmacist services is explored, including evaluating the payer mix, developing a relationship with the first- or third-party payer, becoming credentialed with a third-party payer, and creating a fee structure. We detail the physical process of billing, which involves completing appropriate billing forms, appropriately using billing codes, documenting cognitive services in the patient record, and obtaining the proper waivers and/or approvals to provide specific services such as laboratory services and immunizations. This comprehensive review of compensation for cognitive services available in the community pharmacy and physician office environment is designed to be a template for pharmacists to further develop specific strategies, implement fee structures, and obtain compensation in their pharmacy environment and payer mix. Exploration into these innovative markets will enable pharmacists to increase revenue as they enhance and expand their cognitive services for patients.

Accounts Payable and Receivable↗

PubMed1996

Switching the histamine H2 receptor antagonist famotidine to nonprescription status in Canada. An economic evaluation.

The aim of this study was to compare the direct medical costs associated with the treatment of patients with heartburn/nonulcer dyspepsia under 2 scenarios: (i) no nonprescription histamine H2 receptor antagonist (H2RA) is available (the 'status quo scenario'); and (ii) the H2RA famotidine (at a daily dosage of 10mg) is available over-the-counter (OTC) at retail pharmacies (the 'OTC scenario'). We employed a decision analysis model over a 16-week period that considered direct medical costs from 2 alternative perspectives: (i) society, including the cost of self-medication borne by patients; and (ii) a provincial third-party payer for healthcare. Data concerning direct medical costs associated with consumer self-medication and physician prescription of medication (including pharmacist dispensing fees), tests and procedures, and consultations with general practitioners and specialists were drawn from a clinician panel, published unit costs, and special surveys of institutional databases. All costs are reported in 1993 Canadian dollars ($Can; $Can1 = $US0.72, October 1995). From a societal perspective, the expected cost per patient over a 16-week period is not substantially different between the status quo and the OTC scenarios ($Can98 and $Can96, respectively). From a provincial third-party payer perspective, the expected costs per patient for the same scenarios are $Can95 and $Can89, a saving of $Can6 per patient. These results are sensitive to the proportion of patients who initially choose to see their physician rather than self-medicate, and the percentage of patients achieving successful treatment of symptoms. Changes in the rate or the cost of nonprescription medication, tests/procedures and physician visits do not affect the relative cost rankings. The total number of physician visits remained constant in both scenarios. From the societal cost perspective, the availability of famotidine in nonprescription form yields total costs that are similar to the status quo. However, from the perspective of the provincial payer, the expected costs per patient are likely to be slightly lower than the status quo if famotidine is available in unrestricted OTC scenario use. To generate significant savings to provincial payers, the number of people choosing immediate physician contact would have to be reduced, although not substantially, in the OTC scenario.

Canada↗

PubMed2001

Cost effectiveness in Canada of a multidrug prepackaged regimen (Hp-PAC)+ for Helicobacter pylori eradication.

OBJECTIVE: To assess the cost effectiveness of a multidrug prepackaged regimen for Helicobacter pylori, the Hp-PAC (lansoprazole 30mg, clarithromycin 500 mg, amoxicillin 1 g, all twice daily), relative to alternative pharmacological strategies in the management of confirmed duodenal ulcer over a 1-year period from 2 perspectives: (i) a strict healthcare payer perspective (Ontario Ministry of Health) excluding the patient copayment; and (ii) a healthcare payer perspective including the patient copayment. DESIGN: A decision-analytical model was developed to estimate expected per patient costs [1998 Canadian dollars ($ Can)], weeks without ulcer and symptomatic ulcer recurrences for the Hp-PAC compared with: proton pump inhibitor (PPI)-clarithromycin-amoxicillin (PPI-CA), PPI-clarithromycin-metronidazole (PPI-CM), PPI-amoxicillin-metronidazole (PPI-AM) and ranitidine-bismuthmetronidazole-tetracycline (RAN-BMT). MAIN OUTCOME MEASURES AND RESULTS: All PPI-based regimens had higher expected costs but better outcomes relative to RAN-BMT. From a strict healthcare payer perspective, PPI-CM ($Can 209) yielded lower expected costs than PPI-CA ($Can 221) and slightly lower costs than Hp-PAC ($Can 211). However, these 3 regimens all shared identical outcomes (51.2 weeks without ulcer). When the current Ontario, Canada, $Can 2 patient copayment was added to the dispensing fee, Hp-PAC yielded lower costs ($Can 214) than PPI-CM ($Can 216). CONCLUSION: From a strict healthcare payer perspective, Hp-PAC is weakly dominated by PPI-CM with an incremental cost effectiveness (relative to RAN-BMT) of $Can 5.77 per ulcer week averted. When the patient copayment is added to this perspective, Hp-PAC weakly dominates PPI-CM ($Can 5 per ulcer week averted). Regardless of perspective, Hp-PAC and PPI-CM differed by only $Can 2 per patient over 1 year and the expected time without ulcer was 51.2 weeks for both. More data on the clinical and statistical differences in H. pylori eradication with Hp-PAC and PPI-CM would be useful. This analysis does not in clude the possible advantage of Hp-PAC in terms of compliance and antibacterial resistance.

Anti-Bacterial Agents↗

PubMed2003

Validation of expert opinion in identifying comorbidities associated with atopic dermatitis/eczema.

BACKGROUND: The use of expert opinion is widespread in economic studies of healthcare utilisation; however, few studies have attempted to assess the validity of assumptions derived from such sources. OBJECTIVE: To examine the use of such expert opinion in determining comorbidities associated with atopic dermatitis/eczema (AD/E), which were assessed as part of a recent third-party payer cost-of-illness study. DESIGN: To identify the disease-related comorbidities that would represent costs associated with AD/E, physicians on an expert panel were asked individually and then collectively to group all International Classification of Diseases, 9(th) Edition-Clinical Modification (ICD-9-CM) diagnosis codes as 'most likely', 'possibly' or 'definitely not' related to the costs of identifying and treating patients with AD/E. Claims representing $US464 million in payer reimbursements from nearly 125 000 patients with AD/E were identified within two separate claims databases (1997 values). Over 850 ICD-9-CM diagnosis codes were identified in the first-listed position from these claims. For each group of 'most likely', 'possibly' and 'definitely not' related diagnosis codes, prevalence rates were compared within AD/E and non-AD/E populations from the two historical payer claims databases. Adjusted and non-adjusted odds ratios were calculated by comparing prevalence rates between AD/E and non-AD/E patients in the same payer population. RESULTS: The mean prevalence rate of any diagnosis code in the AD/E population was 0.65 +/- 1.82% (SD) with a mean odds ratio of 1.81 +/- 0.96. Comorbidities considered by the expert panel 'most likely' to be associated with AD/E had higher prevalence rates (3.28 +/- 3.63%) and odds ratios (2.14 +/- 1.14). Comorbidities considered to be 'possibly' related to AD/E had prevalence rates and odds ratios of 3.01 +/- 5.06% and 1.84 +/- 0.82, respectively. Comorbidities considered to be 'definitely not' related to AD/E had the lowest prevalence rates (0.45 +/- 1.09%) and odds ratios (1.80 +/- 0.97). CONCLUSIONS: Comparing the result of consensus panels with actual claims histories validated the use of expert opinion in determining comorbidities associated with AD/E. Expert opinion yielded valid results in terms of identifying comorbidities that manifested frequently and disproportionately in the AD/E population. Limited statistical measurements of comorbidities would have been less specific than expert opinion. Future cost-of-illness studies should consider alternative data sources and methodologies to enhance the validity and importance of expert opinion and to corroborate their findings.

Comorbidity↗

PubMed2005

Rizatriptan: a pharmacoeconomic review of its use in the acute treatment of migraine.

Rizatriptan (Maxalt; Maxalt-MLT; Maxalt-Melt) is an oral serotonin 5-HT(1B/1D) receptor agonist (triptan) used in the acute treatment of migraine with or without aura in adults. Rizatriptan 5 mg and 10 mg are effective in relieving the symptoms of migraine and the 10 mg dose provided faster pain relief than sumatriptan 50 mg, naratriptan 2.5 mg, ergotamine/caffeine 2 mg/200 mg and possibly zolmitriptan 2.5 mg, while displaying similar tolerability. Two cost-utility analyses performed from a societal perspective indicated that rizatriptan 10 mg was dominant over ergotamine/caffeine 2 mg/200 mg, sumatriptan 50 mg or 100 mg, naratriptan 2.5 mg, zolmitriptan 2.5 mg and analgesic-based usual care in the acute treatment of migraine. In one analysis also performed from the perspective of a healthcare payer, rizatriptan was still dominant over naratriptan, sumatriptan and zolmitriptan. Rizatriptan was cost effective compared with usual care with an incremental cost per quality-adjusted life-year (QALY) gained of 31,845 Can dollars (2002 values) and an incremental cost per additional attack aborted of 49.82 Can dollars. A modelled cost-effectiveness analysis conducted from a healthcare payer's perspective indicated that almotriptan 12.5 mg was more cost effective than rizatriptan 10 mg as a result of better tolerability. The incremental cost per additional successfully treated patient (defined as being sustained pain free without adverse events) with almotriptan was 6.94 US dollars (1999 values). In other nonmodelled cost-effectiveness analyses, rizatriptan 10 mg, eletriptan 40 mg and almotriptan 12.5 mg most consistently displayed the greatest cost effectiveness in different analyses using different clinical endpoints. A modelled analysis of the costs of migraine-related productivity losses in US corporations indicated that the use of rizatriptan rather than usual care to treat migraines could result in annual cost offsets of approximately 84-118 US dollars (2000 values) per employee in lost productivity avoided. An intervention study in Spanish postal service workers demonstrated that replacement of usual care with rizatriptan reduced the mean per-patient cost of lost productivity per migraine attack from 34.47 euros (2001/2002 values) before the intervention to 13.94 euros and 4.59 euros for the first and second post-intervention migraine attacks. In conclusion, rizatriptan is one of the more clinically effective and therefore cost-effective oral triptans available for the acute treatment of migraine. The available data from cost-utility analyses suggest that rizatriptan is more cost effective than ergotamine/caffeine, simple analgesics, naratriptan, zolmitriptan and sumatriptan. The economic value of rizatriptan depends on the payer's perspective, as the greatest savings can be expected to be achieved in terms of reduced migraine-related loss of work productivity compared with less effective treatments. For healthcare payers, the high acquisition cost appears to be at least partly offset by reduced migraine-related healthcare resource use when compared with usual care. The comparative cost effectiveness of the newer triptans requires further elucidation from comprehensive direct comparisons.

Economics, Pharmaceutical↗

PubMed1994

Health care paper chase, 1993: the cost to the nation, the states, and the District of Columbia.

The U.S. health care payment system is an elaborate and increasingly wasteful paper chase. This article presents new state-by-state estimates of health care administrative costs in the United States, and savings that could be realized with single-payer reform. In 1993, health care bureaucracy will consume 24.7 cents of every health care dollar, a total of $232.3 billion. Administration's share of health spending is up from 23.9 percent in 1987, and from 21.9 percent in 1983. Reducing the cost of administration to Canadian levels by adopting a single-payer health care system would cut U.S. health care bureaucracy by more than half (50.7 percent), saving at least $117.7 billion in 1993. The savings achievable with a single-payer system could fund universal access for the uninsured and improve benefits for the tens of millions of Americans who currently have only partial coverage, without any increase in overall health spending. Reform measures such as electronic billing, insurance industry consolidation, and increased competition (including "managed competition") would save little or nothing on administration. Only a single-payer reform that incorporates the "macro-management" approach to cost control, as in Canada, can achieve significant administrative savings.

Cost Savings↗

PubMed2004

Unpaid radiology claims in New Jersey: incidence and financial implications.

OBJECTIVE: Nonpayment of claims by insurers may lead to major financial losses by physicians. These losses may far exceed the losses from late payment that we studied previously, although it is late payment that has been the primary focus of legislation enacted in 47 states. This article quantifies the loss to radiologists from nonpayment of claims submitted to payers on behalf of patients with insurance. MATERIALS AND METHODS: We analyzed all claims (48,217) submitted in February, June, and October 2000 to six major payers by a common third-party billing company on behalf of 11 radiology practices in New Jersey. Claims were categorized as unpaid (unpaid > 170 days after submission), paid timely (within 40 days of submission, the criterion of the New Jersey Prompt-Pay Act, effective December 28, 1999), or paid late (40-170 days after submission). A detailed analysis of 5,638 claims from the practice of two of the authors was used to estimate a "clean claims" (claims without defect or need for substantiation) submission rate. RESULTS: The revenue loss from unpaid claims was approximately $156,000, which was 28 times the loss of interest that should, according to law, have been paid on the delayed paid claims. Of the unpaid claims, the payers never disputed 68%, involving approximately $106,000. CONCLUSION: The financial consequences of unpaid claims far exceed those associated with late payment, even omitting all unpaid claims that were disputed by payers. Legislation coupled with active enforcement should address this large problem of unpaid claims, which is many times larger than the already legislatively targeted problem of late payment.

Health Maintenance Organizations↗

PubMed2006

Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear. OBJECTIVE: To compare NSTE ACS care patterns by insurance type. DESIGN: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage. SETTING: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005. PATIENTS: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older. MEASUREMENTS: Guideline-recommended treatments, and in-hospital outcomes. RESULTS: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18). LIMITATIONS: Self-pay patients and patients without insurance were not assessed. CONCLUSIONS: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.

Aged↗