SEARCH · PubMed Health

Results for “Payers”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 757 records · Page 42Linked to original sources

PubMed1999

Is the societal perspective in cost-effectiveness analysis useful for decision makers?

BACKGROUND: The U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine recommends that cost-effectiveness analyses (CEAs) intended to help allocate health resources in the public interest include a reference case analysis, conducted from the perspective of society as a whole. This perspective requires that an analysis measure all health effects and changes in resource use caused by an intervention. VALUE OF SOCIETAL CEAs: Tensions unavoidably arise among the parties to medical decisions--patients, their families and friends, clinicians, and third-party payers. One common approach to handling these tensions is to ignore some of them, to "solve" them by pretending they do not or should not exist. Patients do this when they demand the best care for themselves without regard to the cost to others, payers when they make coverage decisions that shift costs ot others. But by estimating all gains and losses, calculations that reflect the safety, effectiveness, and side effects of an intervention as well as its costs, societal CEAs can help resolve those tensions and provide the basis for decisions that are fair to all parties, an agenda for negotiating such decisions, and information essential for designing compensation and incentives to support them. MAKING BETTER USE OF SOCIETAL CEAs: Use of the societal perspective asks that all parties be aware of and consider the interests of others. Some process or procedure needs to be developed for presenting CEA information to the parties most likely to be affected by decisions, soliciting their views, and negotiating an acceptable decision. This process could be used by government decision makers or by managed care organizations, professional societies, or payers.

Attitude to Health↗

PubMed1997

Contracting for services: liver transplantation in the era of mismanaged care.

It is no secret that the health care environment today is motivated by the underlying, largely economic impetus of managed care. This is particularly evident within the organ transplantation community, where third party payers hope to minimize their financial risk by relying more and more on "centers of excellence" networks to provide high-quality transplant services in an economically efficient manner. The burgeoning interest in the economics of liver transplantation raises a number of complex, yet important, issues to which transplant professionals should lend serious thought. This article addresses these issues by offering an elementary guide to contract negotiations with third party payers. Among other things, the article: (1) discusses several methods by which third party payers avert and shift risk to transplant programs; (2) emphasizes the importance and identifies the limitations of actuaries and other consulting; (3) demonstrates, with examples, how comparative analyses of existing data sources, both public and proprietary, can assist rational decision-making.

Actuarial Analysis↗

PubMed1999

Regionalization of perinatal health care: a lesson learned but lost.

Regionalization of perinatal health care has offered appropriate services to mothers and babies as close to their homes as possible. The need for regionalized service has not changed, but the concept has been challenged by the managed care dictate that patients receive referral services at the least expensive option available that qualifies to give that service by virtue of an assigned designation of level of care. When regionalization first became extant, hospitals qualified as tertiary (highest level) perinatal centers if they had neonatologists on staff. Now, however, far more is required of a hospital if it is to qualify to provide the highest level of care available. The so-called national guidelines of perinatal health care do not clearly specify this, and thus hospitals with limited scopes of perinatal services may still be recognized as tertiary or subspecialty centers. Third-party payers contract with such hospitals to provide tertiary care and are able to do so at a lower cost because these hospitals are not capable of offering more complex and thus more expensive services. However, some patients require the more comprehensive services and are at least initially denied them because of the costs involved. I believe it is improper for third-party payers to dictate what services patients receive and where they receive them. This has been and should be the province of physicians and physicians alone. Furthermore, I believe that a more detailed and descriptive system of guidelines for perinatal health care at the state level could help to clarify the true level of functioning of any hospital and thus make it more difficult for third-party payers to opt only for the least expensive services.

Child Health Services↗

PubMed2001

The evolution of Medicare financing policy for graduate medical education and implications for PM&R: a commentary.

Currently, the only explicit payers for graduate medical education (GME) in the United States are the federal and state governments. Of these, Medicare is by far the largest and most predictable payer. Through the prospective payment system, Medicare reimburses teaching institutions for both their direct and indirect costs associated with their GME programs. Because a well-educated workforce benefits patients covered by private, as well as public insurance, various proposals have been advanced to establish an all-payer pool to distribute the financial burden more equitably. Furthermore, Medicare policy affects physician supply. There is increasing recognition of potential physician oversupply, raising policy questions about the government's longstanding support of GME. In comparison with other specialties, physical medical and rehabilitation (PM&R) may receive more favorable treatment under future GME funding plans, for 2 reasons. First, under the formulas used by Medicare, PM&R training slots typically bring in more indirect revenue to teaching hospitals than is consumed in indirect expenses. This makes PM&R a relatively more attractive program to retain in the face of mandated reductions in training slots. Second, in many parts of the country, PM&R is not threatened by oversupply, making cuts less likely. Nevertheless, the high percentage of non-US medical graduates entering PM&R training may make the specialty vulnerable to future reductions in funded training slots.

Education, Medical, Graduate↗

PubMed2003

Declining payments for emergency department care, 1996-1998.

STUDY OBJECTIVE: We describe recent trends in payments from different payer classes and assess their relative importance to the financial solvency of emergency departments. METHODS: We used Medical Expenditure Panel Survey data from 1996 and 1998. The unit of analysis was the ED visit. Primary outcome measures were ED charges and payments. The independent variable of interest was payer class, and therefore, we limited our analysis to those either uninsured or covered by Medicare, Medicaid, or private insurance. RESULTS: From 1996 to 1998, a declining percentage of total charges were paid, from 60.3% to 53.0% (difference -7.3%; 95% confidence interval [CI] -11.3% to -3.5%). Although the percentage of total charges paid by Medicaid, Medicare, and the uninsured remained constant, the percentage of total charges paid by the privately insured declined from 75.1% to 63.4% (difference -11.7%; 95% CI -16.6% to -6.7%). Overall, adjusted mean ED charge increased from 695 dollars to 798 dollars (difference 103 dollars; 95% CI 61 dollars to 146 dollars). Two payer classes experienced statistically significant increases in adjusted mean charge: the uninsured, from 544 dollars to 740 dollars (difference 196 dollars; 95% CI 62 dollars to 330 dollars), and the privately insured, from 658 dollars to 813 dollars (difference 151 dollars; 95% CI 103 dollars to 199 dollars). Although the adjusted mean payment rate for the uninsured remained stable, the adjusted mean payment rate for the privately insured declined from 77.7% to 65.7% (difference -12.0%; 95% CI -13.4% to -10.7%). CONCLUSION: The ability of EDs to provide emergency care to all regardless of ability to pay is increasingly threatened by declining overall payment rates. Cost shifting to fund care for the uninsured is an increasingly untenable financing strategy.

Emergency Service, Hospital↗

PubMed2003

Dental complaints in emergency departments: a national perspective.

STUDY OBJECTIVES: Using nationally representative data, we sought to describe the incidence of emergency department (ED) visits for dental-related complaints for children and adults in the United States. We hypothesized that dental-related ED visits were more likely than other ED visits to have Medicaid or no insurance as the payer. METHODS: We used data from the 1997 to 2000 National Hospital Ambulatory Medical Care Survey, a national probability sample survey of hospital ED visits that is conducted by the National Center for Health Statistics. From these data, all ED visits in which one of the reasons for the visit was toothache or tooth injury were compiled and used to determine national estimates of counts and rates of ED visits for dental-related complaints. Logistic regression analysis on the outcome variable, presentation to the ED with a dental complaint (versus other problem), was performed to determine the association with payer and other covariates. RESULTS: During the 4-year period from 1997 to 2000, there were an estimated 2.95 million ED visits in the United States for complaints of tooth pain or tooth injury, for an average of 738,000 visits annually. Population-based rates and proportion of all ED visits for dental complaints were highest in the 19- to 35-year-old group, accounting for 1.3% of all ED visits and 5.6 ED visits per 1,000 people in this age category. "Dental problem, not otherwise specified" was the most commonly assigned International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis. Multivariate logistic regression results indicated that the adjusted odds of presentation to the ED for a dental complaint compared with other problems were significantly elevated for visits in which Medicaid or self-pay was listed as the payer relative to those with private insurance. CONCLUSION: EDs are an important point of care for dental-related complaints, particularly for individuals who lack private insurance. ED providers should be equipped to triage, diagnose, provide basic treatment, and ensure appropriate follow-up care for dental problems, which may require enhancement of dental training for emergency medicine providers and improved dental care during and after ED visits.

Adolescent↗

PubMed2006

Evaluating the impact of a disease management program for chronic complex conditions at two large northeast health plans using a control group methodology.

The objective of this study was to observe trends in payer expenditures for plan members with one of 14 chronic, complex conditions comparing one group with a disease management program specific to their condition (the intervention group) and the other with no specific disease management program (the control group) for these conditions. The authors used payer claims and membership data to identify members eligible for the program in a 12-month baseline year (October 2001 to September 2002) and a subsequent 12-month program year (October 2002 to September 2003). Two payers were analyzed: one health plan with members primarily in New Jersey (AmeriHealth New Jersey [AHNJ]), where the disease management program was offered, and one affiliated large plan with members primarily in the metro Philadelphia area, where the program was not offered. The claims payment policy for both plans is identical. Intervention and control groups were analyzed for equivalence. The analysis was conducted in both groups over identical time periods. The intervention group showed statistically significant (p < 0.01) differences in total paid claims trend and expenditures when compared to the control group. Intervention group members showed a reduction in expenditures of -8%, while control group members showed an increase of +10% over identical time periods. Subsequent analyses controlling for outliers and product lines served to confirm the overall results. The disease management program is likely responsible for the observed difference between the intervention and control group results. A well-designed, targeted disease management program offered by a motivated, supportive health plan can play an important role in cost improvement strategies for members with complex, chronic conditions.

Case-Control Studies↗

PubMed2004

The economics of telerehabilitation.

This paper is an analysis of the economics of physical telerehabilitation, at home, in the clinic, and at work. This study was a precursor to generating a business case for manufacturing telerehabilitation systems. Pilot studies were performed and structured interviews conducted with providers, payers, patients, and employers. The data obtained were analyzed, in conjunction with published data, to understand the economics with respect to parameters such as lost opportunity costs at work, faster rehabilitation, and cost savings to patients, providers, payers, and employers. The results showed that telerehabilitation has a positive business case with respect to all the stakeholders. The ability to quantify and analyze data from patients remotely is convenient and economical to providers. Patients benefit by getting back to their normal activities faster, both at home as well as work. Telerehabilitation at work allows employees to be treated at work without having to take time to go to a clinic. Lost opportunity costs for employers are minimized when workers return to work faster and are treated onsite. The ability to measure progress quantitatively is beneficial for patients, providers, payers, and employers. Additionally, malingering can be detected and eradicated using telerehabilitation. Proper application of appropriate telerehabilitation technologies makes eminent economical sense. There is a strong business case for the application of telerehabilitation, onsite, in large corporations and therefore is profitable to medical device manufacturers.

California↗

PubMed2004

Quantifying net staffing costs due to longer-than-average surgical case durations.

BACKGROUND: Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. METHODS: Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). RESULTS: Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. CONCLUSIONS: Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.

Anesthesia Department, Hospital↗

PubMed1994

Academic surgical group practices at the dawn of health reform.

OBJECTIVE: The authors collected, analyzed, and interpreted baseline data concerning academic surgical group practices as they function in the contemporary medical marketplace. SUMMARY AND BACKGROUND DATA: Health care reform officially began with President Clinton's recent address to Congress. Features of reform, such as universal coverage, managed competition, and regulation of graduate medical education (GME) challenge academic surgery. Data relevant to the governance, financial status, and market positions of academic surgical practices are not available. A current analysis of revenue sources and uses has not been published. METHODS: The authors used a 158-question survey to obtain information, for 1992, on adaptation to current market conditions, financial performance, and revenue uses in a sample of 100 academic surgical group practices. RESULTS: The response rate was 83%. Seventy-four selected group surveys were analyzed. Twenty-three groups are affiliated with private medical schools; 51 are affiliated with public medical schools. Fifty-seven per cent of the groups have satellite clinic networks, and 78% own or contract with managed-care entities. Eighty-six per cent of the groups derive more than 50% of referrals from outside the academic medical center. Gross revenue median was $35 million (range $10-$101 million). Revenue growth was reported by 66%. Payer mix trends show growth in government and health maintenance organization (HMO) payers. An average of 71% of faculty salaries come from practice. Practice revenues provide 68% of department expenses and 40% of research funds. Graduate medical education is supported directly by 69% of practice groups. CONCLUSIONS: Academic surgical group practices are vulnerable in the current marketplace. Revenue growth will be limited in the future because of weak payer mix and broad support of academic programs, including GME, using clinical income.

Academic Medical Centers↗

PubMed1998

Negotiating strategies for capitation.

The appropriate strategy to employ in contract negotiations will vary, depending on a number of important factors. These include the relative size and power of the network, the conditions of the local market, the strength of the managed-care payer in the market, and a host of other issues. The negotiating strategy ultimately adopted will be in accordance with the organizations overall preference, style, and needs. In approaching any contract negotiation, two key points should be kept in mind. First, networks must recognize they can become more prepared and empowered for contract negotiations through the acquisition of additional information. Second, form contracts can be changed; nothing is set in stone. Despite the frequent statements of payer organizations that the form cannot be modified to meet the provider's unique desires and needs, in most cases a contract can be modified in one way or another to meet the parties' mutual needs and desires. Everything is negotiable: Any party involved in such negotiations should be positive, avoiding conflict; use a problem-solving approach; agree whenever possible--strive to become "we"; acknowledge the payer's interest and position, expressing a desire to compromise; and acknowledge the authority and ability of the assigned negotiator. Once the managed-care contract is consummated, the network should attempt to ensure that the parties get maximum value from the agreement. One step to achieving such a desired end is to identify a leader who will be responsible for overseeing contract implementation and performance and responsible for knowing the requirements of the agreement inside out and for focusing on all other requirements of the managed-care program.

Capitation Fee↗

PubMed1998

Hospitalization for gastrointestinal and liver diseases: the effect of socioeconomic and medical supply factors.

A growing body of research has documented significant variation in health care use between communities. As the health care system is transformed, providers and payers should understand the interaction between a community, its sociodemographic characteristics, and its use of health resources. We describe the association between a population's demographic, socioeconomic, and medical resources and hospital use related to gastrointestinal and liver diseases. We used an all-payer hospital discharge database for Michigan from 1986 to 1988. We identified all medical and surgical hospital admissions during this period from two of the Diagnostic Related Group, Major Diagnostic Categories: No. 6, Diseases and Disorders of the Digestive System; and No. 7, Diseases and Disorders of the Hepatobiliary System and Pancreas. We analyzed age- and sex-specific use rates. Finally, we analyzed the influence of sociodemographic variables from the Area Resource File at the county level, on hospital use, using a Poisson regression model. We noted a significant association between increased hospitalizations and increased age in a community. Hospital beds per capita did not influence admission rates overall, although more hospital beds were associated with more medical admissions. Overall, the total physician supply was associated with more admissions. Finally, the most important socioeconomic variable was education. As the level of education of a county increased, hospital admissions decreased dramatically. The transformation of the health care delivery system presents opportunities and challenges. Understanding the underlying epidemiology of disease and how it interacts with a community's socioeconomic and medical resources or medical supply characteristics will be necessary to meet the community's health needs and to ensure the financial viability of providers. This is especially true when payers use a standard payment in a region, such as Medicare's managed care payment, without adjustments for the underlying population characteristics known to influence use.

Adolescent↗

PubMed2001

Economic impact of community- and nosocomially acquired rotavirus gastroenteritis in Austria.

OBJECTIVE: To determine the average costs per child for rotavirus (RV) acute gastroenteritis from different perspectives, from the hospital's, third-party payer's, pediatrician's and family's perspectives as well as in summary from the societal one. MATERIALS AND METHODS: This cost-of-illness study is based on data collected alongside a 6-month prospective, laboratory-confirmed epidemiologic study that evaluated the disease burden of RV infection in Austrian children < or =48 months of age. The study population at risk to contract a community- and nosocomially acquired acute gastroenteritis comprised 9,687 children. All of the 51 children with community-acquired and 33 with nosocomially acquired RV acute gastroenteritis were included in this analysis. The annual costs were estimated by means of extrapolation. RESULTS: For community-acquired RV acute gastroenteritis, the average costs from the hospital's perspective were EURO (EUR) 97.8, from the third party payer's perspective 95.6 EUR, followed by 29.9 EUR and 9.8 EUR from the family's and pediatrician's perspectives, respectively. For nosocomially acquired RV acute gastroenteritis the average costs from the hospital's perspective were 1,494 EUR and from the third party payer's and family's perspectives 831 EUR and 116.8 EUR, respectively. In summary the average costs from the societal point of view for community-acquired RV acute gastroenteritis were 250 EUR and for nosocomial infections 2,442 EUR. After extrapolation the estimated total annual costs were 7.17 EUR million to 0.97 EUR million (13.6%) caused by community-acquired RV acute gastroenteritis and 6.2 EUR million (86.4%) caused by nosocomial RV acute gastroenteritis. CONCLUSION: This cost-of-illness study clearly demonstrates the great impact of RV acute gastroenteritis, mainly of nosocomially acquired infection, on medical health care costs in Austria. To cut costs efforts in disease prevention should be encouraged.

Austria↗

PubMed1999

Distinctive emergency department usage for injury for workers' compensation cases in Utah in 1996.

To compare emergency department services paid by worker's compensation (WC) with services paid by other payers, a state database of 72,747 emergency department visits for injured adults (ages 21 to 54) in 1996 in Utah was analyzed. WC visits accounted for 21.6% (15,704) of all adult injury visits. The mean emergency department charge for WC visits was $282, and the admission rate was 17 per 1000 visits. The mean charge for other payers was $334, and the admission rate was 43 per 1000 visits. Differences were also found between these groups for Injury Severity Scores and diagnoses. In summary, WC emergency department usage was associated with less severe injuries than was emergency department usage for other payers in Utah in 1996.

Accidents, Occupational↗

PubMedDate not supplied

Racial and economic disparity and the treatment of pediatric fractures.

Disparity in the treatment of various medical conditions in patient groups with differing racial and economic backgrounds has increasingly been reported. This paper examines the relationship between baseline racial and economic factors and the treatment of pediatric long-bone fractures. The 2000 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) was used to retrospectively examine the incidence and treatment of pediatric fractures. Data were included for supracondylar humerus (n = 2,957), femoral shaft (n = 1,726) or radius and ulna forearm fracture (n = 828) as their primary diagnosis were studied. Hispanic (78%) and black (82%) patients were more likely to receive closed reduction with internal fixation (percutaneous pinning) of supracondylar humerus fractures than whites (73%, P = 0.02). Despite a fairly large sample size, differences in treatment of supracondylar humerus fractures across primary payer or income groups were not statistically significant. Patients with femur fractures and private insurance were more likely to be treated with an external fixation device (7.2%) than patients in the Medicaid (3.8%) or self-pay (4.5%) groups (P = 0.015). No statistically significant difference was found in the treatment of forearm fractures across racial, primary payer or income groups. Racial and economic disparity is an important issue in medicine today. This study did demonstrate statistically significant differences in the treatment of pediatric supracondylar humerus across racial groups, with Blacks and Hispanics being more likely to receive percutaneous pinning of these injuries than Whites. Private insurance patients were also more likely to have femoral shaft fractures treated with an external fixator device than patients with Medicaid or self-pay as their primary payer. However, the clinical significance of these differences is not clear. Further research is needed to gain a more complete understanding of disparities in medicine, and their etiologies, in order to work towards optimizing the quality of medical care for all patient groups.

Black People↗

PubMed2005

Maximizing reimbursement from trauma response fees (UB-92: 68X) - lessons learned from a hospital comparison.

BACKGROUND: The trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers' performance in collecting this fee help define methodologies that can enhance reimbursement. METHODS: Our trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center. RESULTS: Out of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars) CONCLUSIONS: Enhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.

Academic Medical Centers↗

PubMed2005

Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study.

BACKGROUND: Microinflammation is linked to cardiovascular disease, and is highly prevalent in dialysis patients. It is logical to postulate that septicemia, a common macroinflammatory occurrence in dialysis patients, contributes to their large burden of cardiovascular disease. METHODS: The Dialysis Morbidity and Mortality Wave 2 was a randomly selected prospective cohort of incident dialysis patients. Admission claims data were used to define and calculate rates of septicemia or bacteremia and cardiovascular events in those with Medicare as the primary payer. Utilizing Cox proportional hazard models we determined the association between baseline access and the development of bacteremia or sepsis, and also the association between bacteremia or sepsis episodes and subsequent cardiovascular events. RESULTS: The 2358 (59%) patients with Medicare as primary payer were older and more likely to have heart failure than those with other payers, but had similar comorbidity-adjusted mortality hazards. Rates of first septicemia, bacteremia, or either condition, were 7.0, 5.9 and 10.4 events per 100-patient years, respectively. Cox regression identified initial dialysis access as the main antecedent of septicemia or bacteremia. Hazards ratios for hemodialysis with permanent catheters, temporary catheters, and grafts were 1.95 (95% CI 1.47-2.57), 1.76 (95% CI 1.29-2.41), and 1.05 (95% CI 0.82-1.35), respectively, while that for peritoneal dialysis was 0.96 (95% CI 0.75-1.23) (reference arteriovenous fistula). After adjustment for baseline factors, septicemia or bacteremia, as a time-dependent covariate, was associated with subsequent death [hazards ratio (HR) 2.33, 95% CI 1.38-2.28], myocardial infarction (HR 1.78, 95% CI 1.38-2.28), heart failure (HR 1.64, 95% CI 1.39-1.95), peripheral vascular disease (HR 1.64, 95% CI 1.34-2.0), and stroke (HR 2.04, 95% CI 1.27-3.28). CONCLUSION: Septicemia appears to be an important, potentially preventable, cardiovascular risk factor in dialysis patients.

Adult↗

PubMedDate not supplied

Denial of hospitalization by insurers for inpatient treatment of medication rebound headaches.

Inpatient treatment with intravenous dihydroergotamine has been remarkably successful in managing chronic daily headaches due to excessive use of analgesics or ergotamine tartrate. Recently we have been denied authorization in appropriate patients for this procedure by third party payers on the grounds that it was "not medically necessary," "based on anecdotal information," or is "an outpatient procedure." Three cases are described in which the insurer's decision was either contested as an issue of substandard care, or the patient elected to pay for the procedure. The outcome in two cases was dramatically favorable, at least from the patient's and the physician's point of view. The third case is currently being appealed. Time and energy spent on combating the position of the third party payer on issues of standards of specialist care should be unnecessary. Publication of standards of care by specialists, and a requirement that these care standards must be provided by third party payers are needed in order that quality medical care can continue in this society.

Analgesics↗