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PubMed1999

Underuse of cardiac procedures: do women, ethnic minorities, and the uninsured fail to receive needed revascularization?

BACKGROUND: Women, ethnic minorities, and uninsured persons receive fewer cardiac procedures than affluent white male patients do, but rates of use are crude indicators of quality. The important question is, Do women, minorities, and the uninsured fail to receive cardiac procedures when they need them? OBJECTIVE: To measure receipt of necessary coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) overall; by patient sex, ethnicity, and payer status; and by availability of on-site revascularization. DESIGN: Retrospective, randomized medical record review. SETTING: 13 of the 24 hospitals in New York City that provide coronary angiography. PATIENTS: 631 patients who had coronary angiography in 1992 and met the RAND expert panel criteria for necessary revascularization. MEASUREMENTS: The percentage of patients who had CABG surgery or PTCA was measured, as were variations in use rates by sex, ethnic group, insurance status, and availability of on-site revascularization. Clinical and laboratory data were retrieved from medical records to identify patients who met the panel criteria for necessary revascularization. Receipt of revascularization was determined from state reports, medical records, and information provided by cardiologists. RESULTS: Overall, 74% (95% CI, 71% to 77%) of patients who met the panel criteria for necessary revascularization had CABG surgery or PTCA (underuse rate, 26%). No differences were found in use rates by patient sex, ethnic group, or payer status, but hospitals that provided on-site revascularization had higher use rates (76% [CI, 74% to 79%]) than hospitals that did not provide it (59% [CI, 56% to 65%]) (P < 0.01). In hospitals that did not provide on-site revascularization, uninsured patients were less likely to have revascularization recommended to them (52% [CI, 32% to 78%]); rates of recommendation for patients with private insurance, Medicare, and Medicaid were 82%, 91%, and 75%, respectively (P = 0.026). CONCLUSIONS: Although revascularization procedures are substantially underused, no variations in rate of use by sex, ethnic group, or payer status were seen among patients treated in hospitals that provide CABG surgery and PTCA. However, underuse was significantly greater in hospitals that do not provide these procedures, particularly among uninsured persons.

Angioplasty, Balloon, Coronary↗

PubMed1990

The burden of health care costs: business, households, and governments.

In this article, the authors recast health care costs into payer categories of business, households, and Federal and State-and-local governments which are more useful for policy analysis. The burden that these costs place upon the financial resources of each payer are examined for 1989 and for trends over time. For businesses, their share of health care costs continues to creep upward compared with other payers and relative to their own resources, despite many changes they are making in the provision of employer-sponsored health insurance to their employees.

Actuarial Analysis↗

PubMed1991

Special report. Integrating managed care. When managed care is a system.

In a comprehensive managed care system, all participants benefit from the improved quality and cost efficiency. When payers, beneficiaries, and providers communicate, share data, and participate in decision making, the result is more appropriate and more cost-efficient care. The following articles take a look at how each player in the health care system benefits from a comprehensive approach to health care. Payers (employers) benefit by being able to track the cost effectiveness of their health care through integrated data systems. Beneficiaries (employees and dependents) benefit by becoming more involved in the decisions being made by providers and third party payers about their care through patient education and advocacy programs. And health care providers benefit by gaining an increased leadership role in directing the management of their patients' care through practice guidelines. These guidelines will help doctors make decisions that lead to high quality care as well as build a foundation for standardized review criteria throughout the industry.

Clinical Protocols↗

PubMed1993

Organizations for health care reform.

The following list is meant as a resource for grassroots organizing for health care reform. Many organizations are stepping up their efforts in response to the imminent announcement of the Clinton administration's health care reform proposals. There are three major national organizations working for the same goals in support of a single-payer system: Universal Health Care Action Network (UHCAN!), a network of health care reform groups with a national clearinghouse in Cleveland, Ohio; Citizen Action, with affiliates in more than 30 states; and Physicians for a National Health Program (PNHP), centered in Cambridge and Chicago and with local chapters in various states. There is also a national organization, Campaign for Health Security, working in support of the American Health Security Act of 1993 (S 491 and HR 1200), the Wellstone-Conyers-McDermott single-payer bill. Many states have health care campaigns supporting a single-payer system, as do many progressive unions.

Consumer Organizations↗

PubMedDate not supplied

Reducing health care costs using claims adjudication software.

An important area for reduction in health care costs is incorrect coding of physician services. Current software systems provide high-volume, consistent claims review with substantial savings for payers. The third generation of such systems offers comprehensive coverage across clinical disciplines, across individual claims, and across an entire history of claims. It is likely that these systems will be useful to both nontraditional payers, such as physician groups and hospital-based networks, and traditional payers seeking to reduce costs and enhance competitiveness.

Cost Control↗

PubMedDate not supplied

Global pricing for cardiac care: hard lessons for physicians and hospitals.

The challenges associated with global contracting are becoming apparent as more experience is gained. Contracts held by an open medical staff hospital provide an ever-changing equation. High-cost physicians can join the staff and alter the cost and quality outcomes that the hospital and physicians may anticipate. Also, physicians want to have assurances on how fee distribution is determined. For these reasons, some physicians are developing private contracting vehicles that assure their future. Managed competition is encouraging these creative models to respond to the market demands of payers; in some markets, these vehicles are creating the demand. It is important for both physicians and hospitals to be open to new creative models. Hospitals that insist on controlling the situation decrease its potential success. Flexibility ensures the ability of both entities to respond to new market demands. From the payer perspective, global contracting represents predictability of price and dependability of service. It encourages an economic relationship of dependence between a hospital and its physicians. Utilization of service is no longer the payers' problem; instead, the provider is asking the questions and managing the situation to assure that both quality and economic efficiency outcomes are achieved.

Cardiology Service, Hospital↗

PubMed1993

Untangling healthcare competition.

Traditional approaches to competition may be inappropriate for healthcare providers. Neoclassical economics makes the implicit assumption that a single actor embodies consumption, compensation, and benefit from a transaction. In healthcare, this assumption does not hold. Instead, such actions are accomplished by three separate actors--consumers (physicians), customers (third-party payers), and clients (patients). A hospital simultaneously competes in three arenas. Hospitals compete for physicians along a technological dimension. Competition for third-party payers takes on a financial dimension. Hospitals compete for patients along a marketing dimension. Because of the complex marketplace interactions among hospital, patient, physician, and third-party payer, the role of price in controlling behavior is difficult to establish. The dynamics underlying the hospital selection decision--that is, the decision maker's expectations of services and the convenience of accessing services--must also be considered. Healthcare managers must understand the interrelationships involved in the three-pronged competitive perspective for several reasons. This perspective clarifies the multiple facets of competition a hospital faces. It also disentangles the actions previously fulfilled by the traditional single buyer. It illuminates the critical skills underlying the competition for each audience. Finally, it defines the primary criterion each audience uses in sorting among hospitals. Recognition of the multifaceted nature of competition among healthcare providers will help demystify market behavior and thereby improve internal organizational communication systems, managers' ability to focus on appropriate activities, and the hospital's ability to adapt to changing market conditions.

Catholicism↗

PubMed1994

Diffusion of Medicare's RBRVS and related physician payment policies.

In 1992, Medicare reformed its physician payment method by implementing the Medicare fee schedule (MFS), of which the resource-based relative value scale (RBRVS) is a major component. Using a recent survey and case studies, we examine the diffusion of Medicare's RBRVS to non-Medicare payers and how those payers use and perceive the RBRVS and MFS policies. We find that approximately one-third of payers that participated in the survey have adopted RBRVS-based payment systems in varying degrees while another 40 percent were seriously considering its adoption. Prospects for expanded use of Medicare's RBRVS appear favorable.

Cost-Benefit Analysis↗

PubMed1995

Capitation and informatics.

When physicians, hospitals, and allied health professionals bill for services they render, their information processing requirements are relatively simple, at least compared to those of capitated organizations. When payers (insurers or employers) accept financial risk for the health care services of beneficiaries, they have usually invested in claims processing, membership tracking, and, under managed care, utilization review and provider profiling systems. But payers, for the most part, have not invested in electronic collection of clinical information about beneficiaries, nor have they tended to keep all claims they have processed in electronic form for study after accounts are settled and payments disbursed. In this article, we will explore why informatics is so important to capitated organizations and why payers that have traditionally taken financial risk for insuring the health care costs of populations are also learning about the importance of informatics.

Capitation Fee↗

PubMed1992

Integrated business office can boost cash flow.

Management of patient accounts traditionally has treated billing and collections as separate functions, with staff members working accounts alphabetically by patient. In an integrated business office, however, staff members are trained in both billing and collections and are specialized according to payers. The advantages of a payer-specific design include more efficient contact with major payer groups and a better trained, more flexible staff.

Accounts Payable and Receivable↗

PubMedDate not supplied

Cost-containment strategies for centers offering open heart product lines: one conceptual model.

Those hospitals currently offering cardiovascular service lines must look carefully at cost and outcome criteria. Certain considerations, such as the aging population, declining reimbursement rates, more critically ill patients and advances in healthcare technology, may be cause for many hospital administrators to rethink the viability of offering open heart services. The sometimes brutal competition in healthcare threatens the existence of many smaller programs. Some may argue that the corporate culture of healthcare is fast becoming more and more bottom-line oriented. True, the bottom line is important, but at what point is quality affected? The concept of managed care and capitated fees has, in effect, sent third-party payers into a "feeding frenzy" with respect to contract negotiations. This often results in the pitting of one hospital or doctor against another in what could be argued to be a calculated effort to drive down cost. Health-service organizations performing open heart surgery must understand a multitude of political and economic factors in order to provide cost-effective care. At the top of the priority list must be quality of care. Programs which experience low mortality/morbidity rates will be those facilities that consumers and payers choose. In fact, adjusted mortality/morbidity reports are already a reality in some states. Successful heart programs will be those known in the community (and, perhaps more importantly, to payers) as "centers of excellence," which offer customers high-tech and cost-conscious healthcare. Paramount to successful heart programs will be variables such as favorable managed-care contracts, program size, peer review and proactive case management.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗

PubMed1998

Ensuring adequate payment for the use of new technology.

To ensure that proper reimbursement is obtained for utilization of a new technology, providers should demonstrate to payers the long-term cost-effectiveness of the new technology. Providers need to determine the incremental costs incurred in using the technology and various payers' payment rates for such use. If preliminary analysis shows that reimbursement for the technology may be insufficient, providers then should conduct a detailed analysis of the new technology. This analysis should assemble comparative data of internal and external performance benchmarks from various sources, including state, regional, and national databases. In addition, providers should assess the long-term savings achieved by using the new technology, such as reductions in hospital readmissions and repeated procedures. Managed care payers are likely to find such data persuasive in determining whether to increase payment rates for a new device or therapy.

Angioplasty, Balloon, Coronary↗

PubMed1998

Medical care collection or recovery--VA. Proposed rule.

This document proposes to amend VA's medical regulations concerning collection or recovery by VA for medical care or services provided or furnished to a veteran: For a non-service connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a health-plan contract; For a non-service connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or For a non-service connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance. Previously, by statute VA was authorized to charge "reasonable costs" for such care or services. However, amended statutory provisions now authorize VA to charge "reasonable charges." Accordingly, this document proposes to establish methodology for charging "reasonable charges" consistent with the statutory amendment. Under the proposal, the charges billed using this methodology, as appropriate, would consist of inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, physician charges, and non-physician provider charges. Reasonable charges for outpatient dental care and prescription drugs not administered during treatment would continue to be billed using the existing cost-based methodology. Pursuant to statutory authority, VA has the right to recover or collect the charges from a third party to the extent that a provider of the care or services would be eligible to receive payment therefor from that third party if the care or services had not been furnished by a department or agency of the United States. With respect to a third-party payer liable under a health plan contract, consistent with the statutory authority, the third-party payer would have the option of paying to the extent of its coverage, either the billed charges or the amount the third-party payer demonstrates it would pay for care or services furnished by providers other than entities of the United States for the same care or services in the same geographic area. Using the methodology in this proposed rule, the data for calculating actual amounts for the various inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, and physician charges at individual VA facilities for the period August 1998 through September 1999 are set forth in a companion document published in the "Notices" section of this issue of the Federal Register. Also, under the proposal, the regulations would be clarified to state specifically that billing methodology based on costs will continue to be applied to establish charges for medical care furnished in error or on tentative eligibility, furnished in a medical emergency, furnished to certain beneficiaries of the Department of Defense or other Federal agencies, furnished to pensioners of allied nations, and furnished to military retirees with chronic disability.

Accounts Payable and Receivable↗

PubMed1984

How can PPOs control prices without violating antitrust laws?

Preferred provider organizations (PPOs) have caused concern because they raise the question whether providers can establish mechanisms to control the price of medical care without violating antitrust laws. The U.S. Supreme Court recently decided in Arizona v. Maricopa County Medical Society that the practices of a physicians' organization which set fee schedules by majority vote constituted price fixing because "independent competing entrepreneurs" made the agreements. The decision implies that PPOs must carefully structure collective efforts to set prices in order to avoid unlawful agreement among competitors. To avoid antitrust exposure, hospitals may independently determine prices and contract individually with providers, or they may act as brokers for individual physicians, establishing fees and claims-processing procedures and then contracting with physicians who agree to these requirements. Setting fees independently may be difficult, however, since hospitals need to know what payment physicians will accept. Thus some physician involvement is probably inevitable. No antitrust liability results, however, if individual physicians are sampled in an information-gathering process but do not collectively set fees. In addition, a PPO that is structured as a partnership or other joint arrangement involving true risk sharing should withstand antitrust challenge. In recent business review letters, the Department of Justice approved two different PPO structures: A Hospital Corporation of America subsidiary would contract (nonexclusively) with providers, hospitals, and third party payers to treat the third party payers' beneficiaries at discounted rates. The charges would be negotiated individually with each physician and hospital. A management consultant firm would act as an intermediary between providers and third party payers, negotiating patient discounts but not participating in fee setting. A PPO need not be structured in every respect like these programs. Individual situations vary, and with sound antitrust advice, PPOs can avoid legal pitfalls.

Economic Competition↗

PubMed1980

Hospital collective bargaining: structure and process.

The increasing influence of third parties on collective bargaining has continued to interest labor relations practitioners. The authors discusses the role of third-party payers and state regulatory agencies in labor-management negotiations at voluntary hospitals. Highlighted is the bargaining strategy adopted by negotiators when collective bargaining operates under a prospective rate-setting system. Also presented are the economic variables by which the payers influence hospital-union relationships and their effect on the outcomes of bargaining. The author describes the political context of health-care bargaining and the growing significance of cost control on hospital negotiations. He concludes that third-party payers cause health-care bargaining to change from a bilateral structure to a multilateral dimension.

Collective Bargaining↗

PubMed1999

Medical care collection or recovery. Department of Veterans Affairs. Final rule.

This document amends VA's medical regulations concerning collection or recovery by VA for medical care or services provided or furnished to a veteran: (1) For a non-service connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a healthplan contract; (2) For a non-service connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or (3) For a non-service connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance. Previously, by statute VA was authorized to charge "reasonable costs" for such care or services. However, amended statutory provisions now authorize VA to charge "reasonable charges." Accordingly, this document establishes methodology for charging "reasonable charges" consistent with the statutory amendment. The charges billed using this methodology, as appropriate, consist of inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, physician charges, and non-physician provider charges. Reasonable charges for outpatient dental care and prescription drugs not administered during treatment will continue to be billed using the existing cost-based methodology. Pursuant to statutory authority, VA has the right to recover or collect the charges from a third party to the extent that a provider of the care or services would be eligible to receive payment therefore from that third party if the care or services had not been furnished by a department or agency of the United States. With respect to a third-party payer liable under a health plan contract, consistent with the statutory authority, the third-party payer continues to have the option of paying, to the extent of its coverage, either the billed charges or the amount the third-party payer demonstrates it would pay for care or services furnished by providers other than entities of the United States for the same care or services in the same geographic area. Also, the regulations are clarified to state specifically that billing methodology based on costs will continue to be applied to establish charges for medical care furnished in error or on tentative eligibility, furnished in a medical emergency, furnished to certain beneficiaries of the Department of Defense or other Federal agencies, furnished to pensioners of allied nations, and furnished to military retirees with chronic disability.

Accounts Payable and Receivable↗

PubMedDate not supplied

Next generation software systems provide tools for handling complexity of billing codes.

Medical practice staff members, intent on assuring accurate and prompt reimbursement by an increasing number of payers for services rendered to the practice's patients, face what often feels like an insurmountable challenge. Ever-changing and differing reimbursement rules create a frustrating environment in which it is difficult, if not impossible, to comply with payers' requirements. This article provides an overview of a new generation of automated systems that offers physicians the ability to submit bills that more precisely comply with payers' expectations. It describes how claims editing software systems work and capabilities staff should consider before choosing a system.

Efficiency, Organizational↗

PubMed2001

Internet-based eligibility verification lowers costs, improves payment timeliness.

Verification of claims eligibility traditionally is performed either through telephone communication between the payer's and provider's staff or through an EDI clearinghouse. These forms of verification offer inconsistent quality, often use out-of-date information, cost time and money, and may financially harm payers and providers by leading to delays in payments or claims denied after care has been rendered. Internet-based eligibility verification software reduces the number of rejected claims because it can access current information without using a clearinghouse. The software also allows earlier collection of copayments because these obligations can be identified accurately when care is rendered. By offering Internet-based eligibility verification, payers can help providers achieve financial benefits while gaining such benefits themselves.

Boston↗