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PubMed2001

Knowledge is payment: understanding state prompt-payment laws.

Faced with lagging receivables, hospitals across the country increasingly are suing delinquent payers to obtain payment. States have responded to the provider payment crisis by enacting and enforcing a rash of new laws requiring payers to pay claims within strict time frames or face steep penalties. To take advantage of the protection afforded by these laws, providers need to be aware of prompt-payment statutes in states in which they provide care, in which their patients live, and in which their payers are located. By becoming aware of their rights and obligations under these laws, providers can use the prompt-payment regulations proactively to avoid payment backlogs without resorting to litigation.

Accounts Payable and Receivable↗

PubMedDate not supplied

Management of caries in the child three years of age and younger: a survey of post-doctoral pediatric dentistry program directors.

PURPOSE: The purpose of this study was to report the results of a survey of pediatric dentistry post-doctoral program directors regarding education of post-doctoral students about management of caries in children 3 years-of-age or younger. METHODS: Fifty-two pediatric dentistry advanced education program directors were sent questionnaires inquiring about payer sources in their programs, distribution of caries in children 3 years of age or younger within the payer sources, the methods they teach and use to treat the caries, and the effectiveness of treatment and outcome data about the success of their treatment. RESULTS: Twenty-nine programs responded (56%). On average, two-thirds (66%) of the patients in post-doctoral pediatric dentistry programs are Medicaid patients. Program directors are fairly uniform in how they define methods of caries management, and they rate definitive therapy as the most effective method to manage all types of caries. Literature/textbooks were most frequently cited as the major source of scientific evidence to support treatment decisions. Fewer than 20% of program directors have outcome data on the effectiveness of their methods of treatment. CONCLUSIONS: Medicaid is the major payer source for patients in post-doctoral programs and definitive therapy is considered by program directors to be the most effective approach to managing caries in this patient population. Program directors rely on the literature and textbooks and few have outcome data.

Administrative Personnel↗

PubMed2001

How do Trends for Behavioral Health Inpatient Care Differ from Medical Inpatient Care in U.S. Community Hospitals?

BACKGROUND: Inpatient care in the United States accounts for one third of the health care expenditures. There exists a well-established trend towards fewer inpatient admissions and shorter lengths of stay for all inpatient care, which can be attributed to cost containment efforts through managed care and advances in treatment technologies. However, different illnesses may not necessarily share the same pattern of change in inpatient care utilization. In particular, mental health and substance abuse (MHSA) care has experienced a particularly dramatic growth of specialized managed behavioral organizations, which could have led to an even faster decline. AIMS OF THE STUDY: This study contrasts the trends of MHSA inpatient care in U.S. community hospitals with medical inpatient care over the years 1988 to 1997. It also analyzes the trends for subgroups of MHSA stays by diagnostic groups, age and primary payer. METHODS: We use the National Inpatient Sample (NIS) from the Health Care Cost and Utilization Project (HCUP) to estimate both number of inpatient discharges per 1,000 population and average length of stay over the years and relate the two indices. Inpatient MHSA stays are categorized into subgroups by age, primary payer of the care, and diagnostic group. We use the Clinical Classification Software (CCS) to distinguish between affective disorders, schizophrenia and related disorders, other psychoses, anxiety and related disorders, pre-adult disorders, and alcohol-, substance- related mental disorders and other mental disorders. Trends of population adjusted discharges and length of stay were tested using a weighted least squares method. RESULTS: Population-adjusted MHSA discharges from community hospitals increased by 8.1% over the study period, whereas discharges for all conditions decreased. Within MHSA discharges, the 20-39 and 40-64 age groups experienced significant increase relative to other age group; the increase was particularly high for affective and psychotic disorders, which are only partially offset by a decrease for other diagnostic groups. Hospitalization for both MHSA and medical conditions displayed trends towards shorter lengths of stay, but with the decline for MHSA stays steeper (40%) than for all stays (21%). The reduction in length of stay not only applied to the privately insured, for which managed behavioral health care had the highest penetration rate, but held for all other payers as well, although the rate of decline is higher for private insurance than for other insurance. Inpatient stays with pre-adult disorders displayed the greatest percentage decline for both population-adjusted discharges and average length of stay. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Different pattern of utilization emerged for MHSA inpatient care as compared to hospitalization for all medical care over the years 1988-97. The more rapid decline in length of stay for MHSA stays than for all stays may have been a result of greater incentive for cost containment and therefore more intensive care management, and advances in treatment technology, especially medication. However, the fast decline in length of stay may also have led to repeat hospitalization as a result of premature discharges for patients with affective or psychotic disorders. Some financial incentives, such as case-rates or DRG-type payments to hospitals could have contributed to such adverse effects. Increases in discharges for severe disorders could also be a consequence of shifts from long-term facilities (for which no comparable data are available) to community hospitals, although the largest absolute and relative increases were for affective disorders rather than schizophrenia or other psychoses, the two disease subgroups that make up the majority of the institutionalized patients. International comparisons, assisted by new data, may help disentangle the effect of institutional change and that of development in treatment technology or practice pattern.

Journal Article↗

PubMedDate not supplied

Beating the odds: reducing the risk of not being paid by HMOs and IPAs.

Physicians are having increasing problems getting paid by HMOs, independent practice associations and other payers. This article discusses what practices should investigate about payers, and guidelines for negotiating protections in contracts with payers. Even if certain clauses cannot be negotiated, it is important that providers be aware of potential traps in the contract. By using these guidelines, physicians will be able to negotiate better contracts or decide that no contract is better than a bad contract.

Guidelines as Topic↗

PubMed2003

Defining and characterizing the late-stage biopharmaceutical pipeline.

OBJECTIVE: To identify and describe biopharmaceuticals in late-stage development in the United States and to understand their implications for third-party payers. STUDY DESIGN AND METHODS: "Biopharmaceutical" and biopharmaceuticals in late-stage US development (had completed Phase 2 or higher) were identified through reviews of literature, 4 drug-development databases, a clinical trial database, and informal telephone conversations with representatives of the US Food and Drug Administration, faculty at academic institutions, and manufacturers. RESULTS: "Biopharmaceutical" was defined as "any biology-based therapeutic that structurally mimics compounds found within the body." This includes recombinant proteins, monoclonal and polyclonal antibodies, peptides, antisense oligonucleotides, therapeutic genes, and certain therapeutic vaccines. As of April 2003, there were 102 unique biopharmaceuticals in late-stage development for 156 indications in 36 disease categories, affecting at least 22 distinct physician specialties. Cancer agents are most common, with 30 agents (29%) targeting 62 indications (40%). Nearly 90% of the biopharmaceuticals require administration via injection or infusion, nearly 70% will require administration by a healthcare provider, and more than 60% will be administered in ambulatory care settings. All 22 physician specialties are affected by healthcare provider-administered biopharmaceuticals. Excluding cancer-related biopharmaceuticals, 60% of biopharmaceuticals and 54% of indications require chronic administration. Up to 81 biopharmaceuticals for 123 indications may be approved within the next 4 years (including secondary approvals). CONCLUSIONS: The broad range of the late-stage US biopharmaceutical pipeline has significant implications for third-party payers due to their likely premium price, once approved, as well as novel logistical considerations. Payers must prepare for a wide range of clinical, administrative, delivery, and economic issues.

Biopharmaceutics↗

PubMed2004

Issues and challenges for managed care in the treatment of asthma and chronic obstructive pulmonary disease.

Managed care organizations (MCOs) and payers have become increasingly aware of the impact of asthma and chronic obstructive pulmonary disease on healthcare expenditures. The prevalence and incidence of both conditions continue to increase, even as new therapeutic modalities enter the market to offer treatment alternatives for these conditions. Although viewed by most payers as long-term conditions with expenditures that will not diminish, MCOs and payers have become more concerned with controlling costs and ensuring appropriate utilization.

Asthma↗

PubMed2005

The Oral Health Information Suite (OHIS): its use in the management of periodontal disease.

Health care costs continue to increase at a rapid rate. Dental costs alone have risen from $31.5 billion in 1990 to $70.3 billion in 2002, outpacing inflation by 160 percent. Payers for health care services have no means to evaluate the value of these large expenditures. Quantified information is not available regarding a patient's condition prior to and after treatment nor on the probability of future disease. The absence of this information prevents dentists from responding effectively to challenges by payers and patients, and specifically prevents dentists from effectively influencing the quality of periodontal care. We have developed a user-friendly Internet-based technology that quantifies risk for periodontitis and periodontal disease severity and extent and generates recommended treatments and interventions. A caries risk assessment tool has also been developed, and an oral cancer assessment tool is being developed. This technology, designated the Oral Health Information Suite (OHIS), provides quantitative information to the clinician and patient as an aid to diagnosis and to facilitate individual, needs-based treatment planning. OHIS enables successful application of the wellness model of oral health care, which may be expected to result in more uniform and accurate clinical decision making, improved oral health, reduction in the need for complex periodontal therapy, reduction in oral health care costs, and improved clinician productivity and income. It also will permit patients to become more involved in their oral health care, payers to quantify and predict their health care expenditures, dentists to experience an increase in trust and respect, and periodontists to be more properly consulted regarding periodontal care.

Adult↗

PubMed2005

Responses of hospital utilization review staff to reimbursement denials.

Utilization review (UR) is a strategy used by the managed care industry to monitor and control utilization of health care resources. The concurrent UR process requires that hospital staff report clinical information to payers, who either certify or deny reimbursement. Conflicts may arise when hospital staff disagree with denial decisions. The authors analyzed the various responses of a medical center UR staff to payer denials and found that although denials were not frequent, they were perceived negatively by hospital staff. Improving and standardizing communication among providers, payers, and patients is one means of reducing conflict and frustration in the event of reimbursement denial.

Academic Medical Centers↗

PubMed2006

New kid in town.

Hospitals can prepare for APC-based systems by: Paying close attention to the modifications that state payers make to Medicare's APC policies. Proactively monitoring and adjusting billing practices to be as consistent with the state payers' APC billing requirements as possible, even if the billing requirements have no effect on current payments for services. Analyzing the ways in which state payer APC policies vary from Medicare to anticipate the impact of these systems on their hospitals' operations and financial condition.

Economics, Hospital↗

PubMed2006

Toward evidence-based assessment for coverage and reimbursement of laboratory-based diagnostic and genetic tests.

Despite the pervasiveness of laboratory tests and their importance to medicine, evidence for their appropriate use often is very limited. In this article, we argue for a fundamental restructuring of the process by which laboratory tests are evaluated and reimbursed. We present an approach that would promote more evidence- based appraisals for laboratory tests. In addition, we urge that coverage and reimbursement for laboratory tests move toward an evidence- and value-based approach, using the tools that largely have been adopted for pharmaceuticals by many US healthcare payers. To address this information gap for laboratory tests, we note several potential strategies to encourage manufacturers, laboratory service providers, and payers to collect outcome and cost data that will better support effective use of new laboratory tests. Integral to increasing appropriate use and reimbursement will be the development of a common language and format for dialogue--facilitating the development, review, and delivery of evidence-based tests by manufacturers, clinical laboratories, and healthcare payers.

Clinical Laboratory Techniques↗

PubMed1991

National health insurance and the problems of American medicine.

The problems of inequitable access to care, health care inflation, and reduced physician autonomy confront physicians and health care reformers with a dilemma. Piecemeal measures attempting to alleviate one problem in isolation simply exacerbate the others. A logical approach to addressing these problems together is a national health program based on a single payer of health services. By reducing administrative waste and emphasizing global budgetary strategies, the single-payer system could promote more efficient health care spending. While single-payer systems create more explicit political conflict over resource allocation, they also have demonstrated an ability to maintain quality of care and reduce bureaucratic intrusions into clinical practice.

Canada↗

PubMed1990

[The covering physician system from the viewpoint of the insurance company].

The main question is: To whom and according to which regulations does the nonresident physician bill for reimbursement? The analysis brings to evidence, that different answers have to be given for each kind of treatment (outpatient medicine, care in ambulatory settings of hospitals, and inpatient medicine). Moreover, each kind has to be looked at differently with regard to three categories: (1) the patient who pays himself (self payers scheme), (2) the patient who is subject to the social illness insurance, and (3) the one is subject to the compulsory social accident insurance. The whole matter is extremely complex, and thus little understood as well by the nonresident physician as by the patients. Furthermore, economic disparities are apparent when looking at the various social insurance legislations, and when considering the medical tariff of each social insurance scheme. Obviously, the self payer schemes are simple, transparent and thus better understood: The nonresident physician bills to the patient directly, who in term owes payments, regardless whether he is insured or not. This system applies to all non-social insurance schemes, particularly to the private insurance scheme. Yet, the self payers schemes are successful only when State and local governments reduce their subsidies and grants to their own hospitals, and if all medical services are paid on an effective cost basis: in order to give equal chances to all medical services, private and public. Thus, the patients' position would be uprated. At the same token, the nonresident physicians would have firmer chances which in turn would mean an enormous advantage to their patients since they could be treated by one and the same physician before, during and after their hospital stays.

Fees, Medical↗

PubMed1989

The 1987 US hospital AIDS survey.

In 1987, the National Public Health and Hospital Institute conducted a national survey of 623 acute-care hospitals to obtain information relating to inpatient and outpatient care for persons with acquired immunodeficiency syndrome (AIDS). Two hundred seventy-six hospitals reported treating persons with AIDS; the average length of stay was 16.8 days. Average costs and revenues per inpatient day were $681 and $545, respectively, with a cost per patient per year of $17,910. Estimated cost for AIDS inpatient care during 1987 was $486 million; Medicaid represented the primary payer. Regional and ownership comparisons for this year and between 1985 and 1987 indicated significant differences in utilization, payer source, and financing. Results suggest major differences in reimbursement and losses related to payer source or lack of insurance, with many hospitals that serve large numbers of low-income persons with AIDS encountering moderate to severe financial shortfalls. We conclude that increasing concentrations of persons with AIDS in relatively few hospitals in large cities may make it more difficult to secure the broader political base necessary to obtain adequate support for treatment.

Acquired Immunodeficiency Syndrome↗

PubMed1987

Identifying and managing inappropriate hospital utilization: a policy synthesis.

Utilization review, the assessment of the appropriateness and efficiency of hospital care through review of the medical record, and utilization management, deliberate action by payers or hospital administrators to influence providers of hospital services to increase the efficiency and effectiveness with which services are provided, are valuable but relatively unfamiliar strategies for containing hospital costs. The purpose of this synthesis is to increase awareness of the scope of and potential for these approaches among health services managers and administrators, third-party payers, policy analysts, and health services researchers. The synthesis will assist the reader to trace the conceptual context and the historical development of utilization review from unstructured methods using individual physicians' professional judgment to structured methods using explicit criteria; to establish the context of utilization review and clarify its uses; to understand the concepts and tools used in assessing the efficiency of hospital use; and to select, design, and evaluate utilization review and utilization management programs. The extent of inappropriate (medical unnecessary) hospital utilization and the factors associated with it are described. Implications for managers, providers, and third-party payers in targeting utilization review and in designing and evaluating utilization management programs are discussed.

Diagnosis-Related Groups↗

PubMed1982

Reimbursement for nondistributive pharmaceutical services in hospitals.

The literature on reimbursement, especially by third-party payers, for clinical pharmacy services is reviewed. Allocation of total departmental expenses on a per-dose basis, subsidization of clinical pharmacy services through general pharmacy revenues, and inclusion of service charges with drug-product charges have been used successfully to support clinical services. Identification and documentation of benefits resulting from clinical pharmacy services is a vital element in the justification process; a new service has little chance for approval unless it documents cost savings. Published reports of clinical pharmacy services that obtained third-party reimbursement include programs in a cardiac-rehabilitation unit, patient education and monitoring, pharmacokinetics, and laboratory-results interpretation. Published guidelines for obtaining reimbursement for clinical pharmacy services are reviewed. An eight-point guide for obtaining reimbursement is recommended. It embodies: a commitment by the director of pharmacy, via departmental goals and objectives, to clinical services; presentation and acceptance by various key elements in a hospital's structure; accurate analysis of costs and benefits associated with the services; requests for reimbursement from third-party payers; continued analysis of the services' effects; and communication of experience with the services to the general public and the pharmacy profession. It is concluded that reimbursement by third-party payers is a step in the right direction and that clinical service charges should be separated from product charges. Further program development and research are needed.

Medical Records↗

PubMed1994

Report of the AMA Board of Trustees.

Single-payer proposals that promise to provide universal coverage, maintain fee-for-service medicine, protect physician autonomy, restrain health spending, and simplify reimbursement and billing may appear enticing. However, the Board of Trustees continues to find that single-payer systems with strict global budgets: fail to provide adequate and timely urgent and elective specialty services; continue to encroach on physician autonomy and the physician-patient relationship; neglect changes in technology; have not been able to stabilize health spending; and incur some of the same administrative costs as multiple-payer systems. References for this report are available upon request.

American Medical Association↗

PubMed1994

Attitudes of Washington State physicians toward health care reform.

Attitudes of Washington State physicians about health care reform and about specific elements of managed competition and single-payer proposals were evaluated. Opinions about President Clinton's reform plan were also assessed. Washington physicians (n = 1,000) were surveyed from October to November 1993, and responses were collected through January 1994; responses were anonymous. The response rate was 80%. Practice characteristics of respondents did not differ from other physicians in the state. Of physicians responding, 80% favored substantial change in the current system, 43% favored managed competition, and 40% preferred a single-payer system. Of physicians responding, 64% thought President Clinton's proposal would not adequately address current problems. Reduced administrative burden, a central element of single-payer plans, was identified by 89% of respondents as likely to improve the current system. Other elements of reform plans enjoyed less support. More procedure-oriented specialists than primary care physicians favored leaving the current system unchanged (28% versus 8%, P < .001). While physicians favor health care reform, there is no consensus on any single plan. It seems unlikely that physicians will be able to speak with a single voice during the current debates on health care reform.

Attitude of Health Personnel↗

PubMed1994

Outcomes measurement. It's a concept physicians need to understand.

"The intricate machinery of our health care system can no longer grasp the threads of experience. The mischief that began long before the health care crisis of the 1970s is progressively disabling the vast machinery of medicine. Too often, payers, physicians, and health care executives do not share common insights into the life of the patient. We acknowledge that our common interest is the patient, but we represent that interest from such divergent, even conflicting, viewpoints that everyone loses perspective. As a result, the health care system has become an organism guided by misguided choices; it is unstable, confused, and desperately in need of a central nervous system that can help it cope with the complexities of modern medicine. The problem is our inability to measure and understand the effect of the choices of patients, payers, and physicians on the patient's aspirations for a better quality of life. The result is that we have uninformed patients, skeptical payers, frustrated physicians, and besieged health care executives."

Humans↗