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PubMed1999

Relationship between primary payer and use of proactive immunization practices: a national survey.

OBJECTIVE: To quantify the national use and determinants of proactive immunization practices by examining the relationship to the primary practice payer. STUDY DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. PATIENTS AND METHODS: A stratified random sample of family physicians, pediatricians, and general practitioners across the United States was selected from the American Medical Association master file of physicians list, which included nonmembers. The main outcome measures were use of reminder systems and assessment of immunization rates. RESULTS: Of the 1769 physicians who were contacted, 1236 participated. Use of reminder systems varied by the practice's primary payer: 31% of health maintenance organization (HMO), 41% of Medicaid, 27% of fee-for-service (FFS), and 28% of no predominant payment source physicians reported using a reminder system (P < 0.01). Use of computerized reminders also varied according to practice primary payer (HMO, 68%; Medicaid, 34%; FFS, 51%; and no predominant payment source, 42%; P < 0.01) as did assessment of immunization rates in the practice (HMO, 57%; Medicaid, 40%; FFS, 28%; and no predominant payment source, 30%; P < 0.01). A majority of Medicaid physicians (84%) required a physical examination before immunization, compared to 49% of HMO, 56% of FFS, and 63% of no predominant source physicians (P < 0.01). CONCLUSIONS: The primary payment source of a practice appears to influence use of proactive immunization practices.

Child↗

PubMed2006

Medicare program; Medicare secondary payer amendments. Interim final rule with comment period.

This interim final rule with comment period implements amendments to the Medicare Secondary Payer (MSP) provisions under Title III of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The MMA amendments clarify the MSP provisions regarding the obligations of primary plans and primary payers, the nature of the insurance arrangements subject to the MSP rules, the circumstances under which Medicare may make conditional payments, and the obligations of primary payers to reimburse Medicare.

Humans↗

PubMed1987

Profile of denials of durable medical equipment for SCI patients by third party payers.

The difficulty in obtaining approval for payment of durable medical equipment by third party payers has impeded the rehabilitation program and discharge planning of many spinal cord patients throughout the country for many years. To gain some insight as to the number and level of patients affected, the kinds of equipment denied, the reasons given for the denial, which third party payers were mostly involved and how the patient and his/her family managed to cope or resolve this problem, a survey was undertaken. Letters were sent to 259 members of the American Spinal Injury Association (ASIA) asking them to list representative cases where requests for equipment deemed necessary were denied. Twenty-eight responses from different institutions were received from sixteen states describing 110 patients and 180 pieces of durable medical equipment denied in 1984 and 1985. Manual wheelchairs, motorized wheelchairs, shower/commode chairs, and environmental control units were the four most common equipment items denied by the third party payers. Government agencies ie., Medicaid, Medicare, Vocational Rehabilitation Departments and State Crippled Children's Services were the most frequent deniers, comprising 54% of the total sample. They were followed by private insurance (31%) and Workman's Compensation (3%). By far, the two most common reasons given for denials were: it was not covered by the insurance policy (38%) and it was not medically necessary (30%). Ninety (90) pieces of equipment (50%) were eventually obtained, most often by charity, or through the patient's family resources.

Data Collection↗

PubMed2001

The technical efficiency of hospitals under a single payer system: the case of Ontario community hospitals.

Using DEA, we investigated the impact of ownership, size, and location on the relative technical efficiency of community hospitals in Ontario, which has a single payer system. Consistent with Hansmann's theory of non-profit organizations and contrary to US-based research, we find no significant differences in efficiency across ownership types (government, religious or secular non-profit). Nor do we find significant differences in efficiency by size or location. Our findings suggest that model formulation and differences in payer mix across types of hospitals in the US have a strong influence on the measurement of the hospital ownership-efficiency relationship.

Catchment Area, Health↗

PubMed1997

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system.

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.

Adolescent↗

PubMed1996

Why the United States should adopt a single-payer system of health care finance.

Although nothing could be less fashionable today than talk of comprehensive health care reform, the major problems of American health care have not gone away. Only a radical change in the way the U.S. finances health care--specifically, a single-payer system--will permit the achievement of universal coverage while keeping costs reasonably under control. Evidence from other countries, especially Canada, suggests the promise of this approach. In defending the single-payer approach, the author identifies several political and cultural factors that make it difficult for Americans to obtain a clear view of this option. Finally, the author argues that much discussion of rationing is vitiated by bracketing more systemic questions to which the issue of rationing is inextricably linked.

Canada↗

PubMed2003

Single-payer, defined contribution or portable HRAs: will market-based models prevail?

Rising healthcare costs have created a crisis situation in employee health benefits. For the first time in a decade, the call for a single-payer healthcare system has been renewed. Although the single-payer system might help expand access to care and reduce administrative costs, the potential costs and bureaucracy make its implementation unrealistic. Consumer-centric health benefit models such as defined contribution and portable HRAs are the first attempts by the private sector to involve consumers in the healthcare decision process. Portable HRAs, which treat health benefits as portable assets to be managed and saved over a lifetime, have the potential to reduce employer costs while improving the quality and continuity of care, with equal access to care for all.

Deductibles and Coinsurance↗

PubMed1996

California's Proposition 186: lessons from a single-payer health care reform ballot initiative campaign.

Proposition 186 was an initiative on the November 1994 California ballot which proposed to establish a state single-payer health care program. Although Prop 186 was overwhelmingly defeated in the November 1994 election (73% No, 27% Yes), it accomplished many things. Model legislation was developed showing the feasibility of a specific single-payer program for California. It was placed on the ballot by an unprecedented volunteer signature-gathering effort and was the largest grassroots political campaign fund-raising effort in California history. A novel strategy for the discussion of complex issues through 1500 house parties was launched. Prop 186 was defeated by an insurance industry-led coalition with an anti-government message. Lessons for future efforts include increasing the size and duration of the grassroots organizing and educational effort, and decreasing reliance on conventional political campaign tactics and the mainstream media.

California↗

PubMed2006

Outcomes research collaborations between third-party payers, academia, and pharmaceutical manufacturers: What can we learn from clinical research?

Research collaborations between academic researchers, regulatory agencies, and pharmaceutical manufacturers have made the drug development process more efficient and have frequently supported the successful documentation of quality, safety, and efficacy of pharmaceuticals (the so-called three hurdles). Over recent years issues of drug cost, access, and utilization have moved to center stage, giving rise to a "fourth hurdle approval" process by third-party payers. This requires new forms of collaborative research among new players. This contribution highlights the need for a "triangular" relationship in the field of outcomes research between scientists in academia, third-party payer institutions, and pharmaceutical manufacturers. We discuss, and illustrate by case studies, how successful models of collaboration from the drug development process might be relevant to research activities related to the fourth hurdle. Case studies which may provide useful models for collaborative outcomes research include the "International Conference on Harmonization" process, the voluntary consultation procedures established by drug regulatory agencies, and the Quebec experience in database sharing.

Biomedical Research↗

PubMed1995

The effect of third-party payers on the clinical decision making of physical therapists.

According to Freidson, third-party payers have eroded the political and economic authority of medicine. To what extent is this also true for alternative practitioners such as physical therapists? The effect of Medicare's restrictive guidelines on physical therapy practice in skilled nursing facilities (SNFs) is examined. SNF physical therapists in Connecticut were surveyed (response rate 99%) using a mixture of open-ended and fixed-alternative responses. Results indicate that SNF physical therapists recognize Medicare criteria and view them as important. Twenty-five to 33% of SNF therapists recommend care based on the guidelines. Younger therapists, therapists with fewer years in the field, and contract therapists are more greatly influenced by the guidelines than older, more experienced, staff therapists (P < 0.08). Those who recommend care based on the guidelines may do so because of possible nonpayment for services already rendered, or because they fear loss of their positions. The majority of Connecticut SNF patients who qualify do receive therapy and Medicare coverage. Therapists may use their knowledge of the guidelines to secure services for their patients, or SNFs may be selecting patients that have the best chances for recovery. Like physicians, SNF physical therapists are under pressure from third-party payers to economize and rationalize, but most continue to secure services for their patients.

Adult↗

PubMed2004

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario.

OBJECTIVE: To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents. DESIGN: Retrospective cross-sectional study. SETTING: Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999. PARTICIPANTS: Non elderly nursing home residents (N=5189) admitted to nursing homes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type. RESULTS: A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT. CONCLUSIONS: Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Activities of Daily Living↗

PubMed1997

The missing link: structured dialogue between the payer and provider communities on the costs and benefits of medical rehabilitation.

The costs of medical rehabilitation for catastrophically injured people are significant. To be competitive in the market-place, third-party payers must provide high quality care to their insured populations while guarding against paying for unnecessary or ineffective services. The provider community, meanwhile, has developed new, lower-cost treatment programs for their patient populations. The proper use of all treatment options relative to acuity and complexity of patient disability and handicap is being measured and evaluated now. This article proposes the establishment of Rehabilitation Research Application Forums that would have the purpose of fostering dialogue regarding rehabilitation outcome research and its policy implications for the payer community. It also proposes the routine publication in industry journals of rehabilitation outcomes articles, accompanied by commentary written by individuals who are appointees to the Forum. The purpose would be more rapid and appropriate application of rehabilitation outcomes research.

Communication↗

PubMed2001

Avoiding health insurance crowd-out: evidence from the Medicare as secondary payer legislation.

The cost of expanding health insurance coverage increases when people who would otherwise purchase insurance obtain public coverage. This paper investigates the effects of one of the first efforts to target insurance benefits to the most needy, the 1982 medicare as secondary payer (MSP) provisions. We find strong evidence of low compliance with the MSP both in terms of medical bill payments (payment compliance) and employer-sponsored insurance coverage (coverage compliance). We estimate payer compliance at approximately 33%. Coverage compliance is lower, at under 25%. We find weak evidence that the MSP caused older workers to shift toward MSP-exempt jobs.

Aged↗

PubMed2002

Obtaining evidence for use by healthcare payers on the success of chronic obstructive pulmonary disease management.

Healthcare payers make decisions on funding for treatments for diseases, such as chronic obstructive pulmonary disease (COPD), on a population level, so require evidence of treatment success in appropriate populations, using usual routine care as the comparison for alternative management approaches. Such health outcomes evidence can be obtained from a number of sources. The 'gold standard' method for obtaining evidence of treatment success is usually taken as the randomized controlled prospective clinical trial. Yet the value of such studies in providing evidence for decision-makers can be questioned due to the restricted entry criteria limiting the ability to generalize to real life populations, narrow focus on individual parameters, use of placebo for comparison rather than usual therapy and unrealistic intense monitoring of patients. Evidence obtained from retrospective and observational studies can supplement that from randomized clinical trials, providing that care is taken to guard against bias and confounders. However, very large numbers of patients must be investigated if small differences between drugs and treatment approaches are to be detected. Administrative databases from healthcare systems provide an opportunity to obtain observational data on large numbers of patients. Such databases have shown that high healthcare costs in patients with COPD are associated with co-morbid conditions and current smoking status. Analysis of an administrative database has also shown that elderly patients with COPD who received inhaled corticosteroids within 90 days of discharge from hospital had 24% fewer repeat hospitalizations for COPD and were 29% less likely to die during the 1-year follow-up period. In conclusion, there are a number of sources of meaningful evidence of the health outcomes arising from different therapeutic approaches that should be of value to healthcare payers making decisions on resource allocation.

Attitude of Health Personnel↗

PubMed2003

Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States.

BACKGROUND: The hypothesis of this study was that differences exist among patients with private insurance compared with patients with Medicaid or no insurance, regarding access to the timely treatment of abdominal aortic aneurysms (AAAs) and the outcomes of AAA repair. METHODS: The study comprised 5363 patients aged less than 65 years (mean age, 59 years) with a diagnostic code for intact or ruptured AAA and a procedure code for AAA repair in the National Inpatient Sample for 1995 to 2000. Dependent variables included ruptured AAA, intact AAA, and in-hospital postoperative mortality rates. Independent variables included payer status, median income, race, gender, age, and comorbid disease. Risk-adjusted analyses were performed with the use of binary logistic regression. RESULTS: AAA rupture was most likely (P <.001) to affect patients with no insurance (36%) or Medicaid (18%), compared with patients with private insurance (13%). After an adjustment for case-mix had been made, data showed that patients without insurance had an increased risk of rupture compared with patients with private insurance (odds ratio, 2.3; 95% CI, 1.5-3.5; P <.001). Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%). CONCLUSIONS: Uninsured patients more often seek treatment of ruptured AAAs compared with patients with private insurance. Operative mortality rates in uninsured patients are greater for elective and emergent AAA repair. These data support the tenet that payer status is associated with mortality rates after AAA repair.

Aneurysm, Ruptured↗

PubMed1977

Medical documentation for third-party payers.

Medical documentation of patient care by physical therapy has become a requirement for reimbursement of health services paid by federal and state programs or by other third-party payers. The medical record of physical therapy must satisfy several specific requirements of third-party payers before health services can be reimbursed. The fiscal intermediaries require a precise, written statement of the patient's physical problems, treatment goals and plan, and objective information on the patient's response to treatment. The criteria reflected for third-party payment must be satisfied and evident in succinct and accurate documentation in the medical record. Medical documentation must show evidence of a prescription, medical reason for treatment, a viable discharge plan, outcome of treatment, coordination of medical services, patient instruction, and discontinuance or adaptation of services when necessary. The requirements for third-party payment based on medical documentation are discussed.

Humans↗

PubMedDate not supplied

The economic impact of payer policies after the Rx-to-OTC switch of second-generation antihistamines.

OBJECTIVE: As a result of the over-the-counter (OTC) introduction of loratadine, health plans have been struggling to determine the best policy to incorporate this change within their existing drug benefit structure for second-generation antihistamines (SGA). The objective of this study was to examine the economic impact of payer policies in response to the Rx-to-OTC switch of loratadine. STUDY DESIGN: Decision analysis was used to model the budgetary impact and cost-effectiveness of four policies for SGA benefits for the managed care organization (MCO), employer, and Medicaid perspectives separately. PATIENTS AND METHODS: Outcomes included direct medical costs and lost productivity (employers only), discounted, quality-adjusted life-years (QALYs) saved because of amelioration of allergic rhinitis symptoms and avoidance of unintentional injuries associated with the use of first-generation antihistamines (FGA). Bayesian probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. RESULTS: Providing limited OTC and second-tier prescription benefits would cost approximately 0.13 dollars and 0.30 dollars compared to third-tier prescription benefits for employers and MCOs, respectively, and would save Medicaid 0.02 dollars per member per month (PMPM). Providing limited coverage for OTC loratadine while retaining second-tier prescription benefits for SGA was the optimal policy for a willingness to pay below 26,200 dollars per QALY for all payers. CONCLUSIONS: Offering second-tier prescription and limited OTC benefits provides greater effectiveness and is not significantly more expensive PMPM than discontinuation. Some of the drug savings from limiting coverage of prescription SGA may be attenuated by the cost of lost productivity and direct medical expenditures due to unintentional injuries associated with increased FGA use in addition to the increased cost of therapeutic substitutes.

Bayes Theorem↗

PubMed2003

Costs of rheumatoid arthritis in Germany: a micro-costing approach based on healthcare payer's data sources.

OBJECTIVE: To develop a systematic set of German cost data in rheumatoid arthritis (RA) based solely on valid healthcare payer's cost data sources. METHODS: Retrospectively one year cost data of 338 patients with RA were generated and analysed. The cost data were derived from a major statutory health insurance plan ("Allgemeine Ortskrankenkasse Niedersachsen") and the regional physicians' association ("Kassenärztliche Vereinigung Niedersachsen"). The recently published matrix of cost domains in RA was applied to structure the analysis. Descriptive statistics were used to analyse the data. RESULTS: The total direct costs for the 338 patients during one year (third quarter 2000 to second quarter 2001) were euro 3815 per patient-year. RA related direct costs were euro 2312 per patient-year. Outpatient costs accounted for 73.7%, inpatient costs for 24.0%, and other disease related costs for 2.3% of RA related direct costs. Outpatients cost drivers were RA related drugs (euro 1019 per patient-year), physician visits (euro 323 per patient-year), diagnostic and therapeutic procedures and tests (euro 185 per patient-year), and devices and aids (euro;168 per patient-year). 98 patients were retired prematurely owing to RA related work disability and incurred costs of euro;8358 per retired patient-year. 96 patients were gainfully employed and incurred sick leave costs of euro 2835 per employed patient-year. CONCLUSION: Micro-costing based on healthcare payer's data provides a relatively conservative albeit highly accurate estimate of costs in RA. Both RA related and non-RA related costs must be taken into account. In gainfully employed patients and in patients who receive RA related retirement payments productivity costs exceed direct costs.

Adult↗