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PubMed2005

Myths and memes about single-payer health insurance in the United States: a rebuttal to conservative claims.

Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct "policy research" biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven "myths" are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the "business case"), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.

Health Care Costs↗

PubMed2002

The association of sex and payer status on management and subsequent survival in acute myocardial infarction.

BACKGROUND: Previous reports have generally shown lower utilization of hospital resources and lower survival in women than men with acute myocardial infarction. However, to our knowledge, no reports have described the influence of payer status on the treatment and outcome of women and men with acute myocardial infarction. METHODS: Baseline and clinical presenting characteristics, utilization of hospital resources, and subsequent clinical outcome were ascertained among 327 040 women and men enrolled in a national registry of myocardial infarction from June 1, 1994, to January 31, 1997. Separate Cox regression analyses were performed for Medicare, Medicaid, health maintenance organizations, and commercial payer groups to ascertain variables that were predictive of mortality in the study population. RESULTS: After adjustment for differences in age and other baseline and presenting characteristics, women were significantly more likely than men to die in the hospital (hazard ratio, 1.13; 95% confidence interval, 1.10-1.16), and this difference was greatest among women with health maintenance organization and commercial insurance (hazard ratios, 1.30 and 1.29, respectively), and least among women with Medicare (hazard ratio, 1.07). However, after adjustment for the additional effect on short-term survival of sex differences in the utilization of both pharmacologic treatments administered within the first 24 hours and invasive cardiac procedures, the mortality difference observed for women and men further diminished (hazard ratio, 1.08; 95% confidence interval, 1.05-1.10). CONCLUSION: In this large registry, we did not observe significant variations among payer classes in management and mortality among women and men after acute myocardial infarction.

Aged↗

PubMed2004

Physicians' interactions with third-party payers: is deception necessary?

Published reports indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians. The use of deception has important implications for physician professionalism, patient trust, and rational health policy development. If deception is as widespread as these studies suggest, there may be serious problems in the medical profession and the health care financing systems at the interface between physicians and third-party payers. Deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient.

Deception↗

PubMed1998

Volume responses to Medicare payment reductions with multiple payers: a test of the McGuire-Pauly model.

The effects of changing financial incentives on physician's practice behaviour have long been of interest to researchers and policy makers. We test a model of physician volume response within the context of multiple payers developed by Thomas McGuire and Mark Pauly. A panel data set covering discharges from about 200 hospitals in the US over 45 months is used to carry out the empirical investigation. A fixed-effect model with generalized least squares and instrumental variable specifications is used to compute empirical evidence of volume responses from eight specialties experiencing varying degrees of Medicare payment reductions following the implementation of Omnibus Budget Reconciliation Acts of 1989 and 1990. The empirical findings are compared with McGuire and Pauly's simulated predictions. We note that in examining physician responses to Medicare payment reductions in the context of a multi-payer environment, it becomes evident that only fixing one payer's reimbursement policy is at best a partial solution to cost containment. We echo observations made by other analysts that physician responses to payment changes can be quite complex. Physicians do not all respond to payment reduction in the same way.

Budgets↗

PubMed1997

Economic impact of angioplasty salvage techniques, with an emphasis on coronary stents: a method incorporating costs, revenues, clinical effectiveness and payer mix.

OBJECTIVES: We sought to broaden assessment of the economic impact of percutaneous transluminal coronary angioplasty (PTCA) revascularization salvage strategies by taking into account costs, revenues, the off-setting effects of prevented clinical complications and the effects of payer mix. BACKGROUND: Previous economic analyses of PTCA have focused on the direct costs of treatment but have not accounted either for associated revenues or for the ability of costly salvage techniques such as coronary stenting to reduce even costlier complications. METHODS: Procedural costs, revenues and contribution margins (i.e., "profit") were measured for 765 consecutive PTCA cases to assess the economic impact of salvage techniques (prolonged heparin administration, thrombolysis, intracoronary stenting or use of perfusion balloon catheters) and clinical complications (myocardial infarction, coronary artery bypass graft surgery [CABG] or acute vessel closure with repeat PTCA). To assess the economic impact of various salvage techniques for failed PTCA, we used actual 1995 financial data as well as models of various mixes of fee-for-service, diagnosis-related group (DRG) and capitated payers. RESULTS: Under fee-for-service arrangements, most salvage techniques were profitable for the hospital. Stents were profitable at almost any level of clinical effectiveness. Under DRG-based systems, most salvage techniques such as stenting produced a financial loss to the hospital because one complication (CABG) remained profitable. Under capitated arrangements, stenting and other salvage modalities were profitable only if they were clinically effective in preventing complications in > 50% of cases in which they were used. CONCLUSIONS: The economic impact of PTCA salvage techniques depends on their clinical effectiveness, costs and revenues. In reimbursement systems dominated by DRG payers, salvage techniques are not rewarded, whereas complications are. Under capitated systems, the level of clinical effectiveness needed to achieve cost savings is probably not achievable in current practice. Further studies are needed to define equitable reimbursement schedules that will promote clinically effective practice.

Angioplasty, Balloon, Coronary↗

PubMedDate not supplied

Payer-based case management: perspectives on managing brain-injured patient.

As the payer environment is carved into many segments, each with its own accountability relative to its financial liability, family members, providers, and even other case managers often find it difficult to comprehend the perspectives of the various parties represented. Indeed, one brain injury case I recently evaluated had four payer case managers: one from the patient's health plan, one from a disease management program for his premorbid diabetes, and two from Medicaid-sponsored programs for the disabled. For payer-based case managers, the ubiquitous case manager role confusion compounds product unfamiliarity.

Brain Injuries↗

PubMed2000

Patient, physician, and payer perceptions and misperceptions of willingness to pay for diagnostic certainty.

Little is known about the value patients, physicians, and payers place on intangible attributes of care. Differences in valuations among these groups and misperceptions of value of intangible attributes to other groups can contribute to conflicts about treatment recommendations or coverage decisions. We surveyed patients, physicians, and managed care executives to assess their willingness to pay (WTP) for diagnostic certainty for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). To determine if patients, physicians, and payers accurately perceive each other's valuations of diagnostic certainty, participants were also asked to estimate the WTP of each of the other types of respondents. Patients were most likely, and executives least likely, to value diagnostic certainty. For PUD, 84% of patients, 61% of physicians, and 43% of executives expressed a positive WTP. Median WTP was low for all three groups ($1-9 for patients and physicians; $0 for payers). Physicians and executives both correctly predicted patient WTP. For GERD, 87% of patients, 52% of physicians, and 29% of executives expressed a positive WTP. Executives underestimated patient WTP. For both diseases, physicians' WTP was overestimated by patients and underestimated by executives. The inconsistency in the value that patients, physicians, and managed care executives place on diagnostic certainty indicates the potential for conflict over practice guidelines or access to services. WTP surveys can provide information to aid in anticipating and addressing areas of disagreement.

Cost-Benefit Analysis↗

PubMed2003

The role of value in provider-patient-payer relationships.

Value is becoming a topic of interest to 3 key players in the healthcare field-patients, payers, and providers. This article examines various value definitions and puts forth a composite value definition incorporating cost, quality, and worth elements. A value triad is created to demonstrate how value can be a linking mechanism between patient, payers and providers. Examples are then provided to assist managers in examining the value associated with payers and patients.

Attitude to Health↗

PubMed1995

Payer and provider relationships: the key to reshaping health care delivery.

Though managed care is customarily thought of as the key point of connectivity for payers and providers, reshaping health care delivery requires a strong, united relationship between the two. The return to a health-related mission is a requirement of the new delivery system, which depends on moving beyond disease-based care and medical financing. In the future, community health status will be a strong indicator of success among payers and providers. Community-centered models of care for the underserved are illustrative of the opportunities for relationship building and strategic alignment between payers and providers.

Health Care Reform↗

PubMedDate not supplied

Using a physician-aligned case management model to influence hospital length of stay and payer denials.

The need for physician-hospital alignment is increasingly important with evolving managed care relationships among physicians, health plans, and hospitals. A 310-bed community hospital implemented a physician-centric case management model in October 1999 due to the increasing pressure from managed care to lower hospital lengths of stay, payer denial rates, and overall costs. The medical-surgical inpatient population was chosen as the study group for examining the influence of the new model. Comparative data on average length of stay and payer denied days were reviewed pre- and postimplementation of the new model. The analyzed results showed a decrease in the number of payer-denied days by nearly one third with a relatively stable average length of stay.

Case Management↗

PubMedDate not supplied

Discharge planning: a collaboration between provider and payer case managers using Medicare's Conditions of Participation.

Discharge planning is a legally mandated function for hospitals and is one of the "basic" hospital roles as outlined in Medicare's Conditions of Participation. This article will define discharge planning; describe the steps in the discharge planning process; list rules and regulations that influence discharge planning in hospitals; and compare hospital-based actions with payer-based actions when planning discharges. Case managers who work for payers interact with hospital-based case managers to facilitate the discharge planning process for patients. Those who form this patient-provider-payer triangle will benefit by reviewing the dynamics of the discharge planning process.

Case Management↗

PubMed2007

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.

BACKGROUND: Previous studies have documented that hospitals decrease costs in response to reimbursement cutbacks. However, research concerning how this may affect quality of care has produced mixed results. Until recently, the ability to study changes in patient safety and payment has been limited. OBJECTIVE: The objective of the study was to determine whether changes in 4 hospital patient safety indicator (PSI) rates are related to changes in the generosity of payers over time. DATA AND METHODS: Study data are drawn from 1995-2000 hospital discharges in 11 states in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database. Following the same organizations over time, we estimate hospital fixed-effects regression models of the association of payer-specific time and post Balanced Budget Act (BBA) payment changes with risk-adjusted hospital PSI rates controlling for patient, organizational, and market characteristics. Four PSIs relevant to a large number of patients and hospitals that reflect general care processes are studied. RESULTS: The time trend during 1995-2000 is consistently significantly positive for private and Medicare hospital PSI rates. Thus, after controlling for patient characteristics and organizational and market factors, performance worsened. The trend is less consistent for Medicaid and does not exist for self-pay hospital PSI rates. After adjusting for multiple comparisons, we also find that the Medicare trend is fairly consistently higher than that of the other payers. In contrast, there is a less consistent BBA effect, especially for Medicare.

Financing, Personal↗

PubMed2006

State Medicaid and private payer reimbursement for telemedicine: An overview.

Individual states in the USA were given the option of paying for telemedicine services with Medicaid (i.e. federal health-care funds administered by the state) in 1998, when the Health Care Financing Administration (HCFA) published final rules for Medicare payment for teleconsultations in health professional shortage areas (HPSAs). It was left to telemedicine practitioners in each state to negotiate the scope of the services covered with the state Medicaid office. Three reports of data gathered by 2002-03 surveys on state reimbursement policies have been reviewed, with additional information from a brief informal 2005 survey conducted by the author. In the seven years since 1998, 34 states have added coverage of telemedicine services to their Medicaid programmes, although there are wide variations in service coverage, payment policies, and geographical and other restrictions. There is less published information on private payer reimbursement. One survey performed by AMD Telemedicine (AMD) and the American Telemedicine Association (ATA) showed that over half of the 72 telemedicine programmes in 25 states delivering billable services were being reimbursed by private payers. In 1999, 43% of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22% did so. It appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.

Delivery of Health Care↗

PubMed1991

All-payer ratesetting: down but not out.

In the United States, when the cost-containment paradigm shifted from regulation to competition, all-payer hospital ratesetting went out of favor. After reviewing the published literature and supplementing the existing literature with more current information, the author concludes that all-payer ratesetting is able to meet its multiple objectives of cost containment, reduction of the amount of cost shifting, improvement of access to the uninsured, and increased productivity. At the same time, all-payer ratesetting has not stifled the diffusion of competitive health care systems or new technology, and any impact on length of stay, admissions, and quality of care is small, if it exists at all.

Cost Allocation↗

PubMedDate not supplied

Physicians, payers, and power. The United States is witnessing a struggle for control of healthcare.

From its earliest days, healthcare in the United States has been controlled by providers, that is, by physicians and by hospitals (which, in turn, were also usually controlled by physicians). But this situation is changing. In the 1920s and 1930s, providers created health insurance companies like Blue Cross and Blue Shield to help patients pay for healthcare--to pay, in other words, for those services offered by providers. After World War II, the Hill-Burton program covered the nation with new hospitals. In the 1960s, Medicare and Medicaid eased the healthcare burden of older Americans--and also recapitalized hospitals. Thus providers called the shots in the creation of both the delivery and the payment systems. But in the 1970s, payers began to become more powerful. Now, in the 1990s, they have joined employers in acting to contain rapidly escalating healthcare costs. But even those long disturbed by the arrogance of some healthcare providers are now asking themselves: Is this really what we wanted? Payers are governed by the market; they may well seek, not the best, but the cheapest healthcare available. This is not in the interest of either patients or physicians. A middle ground--a new power alignment--will have to be worked out by patients, physicians, payers, and government.

Delivery of Health Care↗

PubMed1994

The payers' automation challenge.

Despite some success stories, most of the nation's 300 commercial insurers and hundreds of managed care plans are in the earliest stages of using electronic data interchange for health care transactions. However, there are some encouraging signs of progress in the effort to shift to EDI, as more payers offer providers incentives to automate. Payers blame the relatively slow progress on cost, the absence of universally accepted standard electronic formats and uncertainties over the political debate on health reform. But providers say many commercial payers are moving too slowly to automate and are expecting providers to bear too much of the financial burden.

Blue Cross Blue Shield Insurance Plans↗

PubMed1989

Payer segmentation: how to respond.

Knowing which payers are paying how much for which services will become critically important to hospitals as an increasing number of their payers negotiate fixed rates. Only by routinely assessing their payer composition can hospitals be assured that their profitable services remain profitable and their money losers don't place undue hardship on the bottom line.

Financial Management↗

PubMed1989

Medicare as secondary payer and Medicare recovery against third parties--HCFA. Final rule.

These rules-- 1. Update and revise policies dealing with Medicare as secondary payer; 2. Revise policy on the exclusion of services of immediate relatives of the beneficiary or members of the beneficiary's household; 3. Revise policy on the exclusion of services furnished outside the United States; 4. Clarify policy on the "no legal obligation to pay" exclusion as it applies to services furnished to prisoners; and 5. Reflect a recent statutory amendment that provides an additional exception to the exclusion of services that are "not reasonable and necessary". The changes in the Medicare secondary payer provisions reflect amendments made to section 1862(b) of the Social Security Act (the Act) by section 2344 of the Deficit Reduction Act of 1984 (Pub. L. 98-369), section 9201 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. 99-272), and section 4036(a) of the Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203). Separate regulations will be issued to implement section 9319 of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509), which made Medicare secondary payer for certain disabled Medicare beneficiaries under age 65 who are covered under a large group health plan.

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