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PubMed2002

Cash and compassion: profit status and the delivery of hospice services.

OBJECTIVES: To evaluate the relationship of hospice profit status to patient selection and service delivery. DESIGN: We analyzed responses to the 1997 California Office of Statewide Health Planning and Development (OSHPD) annual home care and hospice survey. Outcomes included the percentages of patients with noncancer diagnoses, referred from long-term care, and with government payers; average length of stay (LOS); the intensity and skill mix of nursing services; and potential availability of chemotherapy and radiotherapy. Reduced models controlled for facility type, profit status, urbanicity, and patient-days. Complete models additionally controlled for patient gender, age, race/ethnicity, diagnosis, referral source, and primary reimbursement source. PARTICIPANTS: All 176 licensed California hospices in 1997. RESULTS: We report comparisons of for-profit and not-for-profit hospices as the absolute difference in percentage points between outcomes (e.g., a difference of 40% vs. 50% is reported as a 10 percentage point difference). In reduced models, for-profit hospices reported 17 percentage points more discharges with noncancer diagnoses, 15 percentage points more long-term care referrals, and 8 percentage points more patients with government payers. Average LOS did not differ by profit status. In reduced models, for-profit hospices delivered 0.20 more daily nursing visits on average; this difference was attributable to patient characteristics. The ratio of skilled to total nursing visits was 11 percentage points lower for for-profit hospices compared to not-for-profit hospices in reduced models (7 in complete models). Profit status was unrelated to the potential availability of chemotherapy and radiotherapy. CONCLUSION: For-profit hospices compared to not-for profit hospices serve a higher percentage of persons with noncancer diagnoses, residents of long-term care, and persons with government insurance. Differences in patterns of nursing services among hospices were related to patient characteristics. The potential availability of complex palliative services did not differ by profit status.

Aged↗

PubMed2005

What can a pilot congestive heart failure disease management program tell us about likely return on investment?: A case study from a program offered to federal employees.

In 1999, the Blue Cross and Blue Shield Federal Employee Program (FEP) implemented a pilot disease management program to manage congestive heart failure (CHF) among members. The purpose of this project was to estimate the financial return on investment in the pilot CHF program, prior to a full program rollout. A cohort of 457 participants from the state of Maryland was matched to a cohort of 803 nonparticipants from a neighboring state where the CHF program was not offered. Each cohort was followed for 12 months before the program began and 12 months afterward. The outcome measures of primary interest were the differences over time in medical care expenditures paid by FEP and by all payers. Independent variables included indicators of program participation, type of heart disease, comorbidity measures, and demographics. From the perspective of the funding organization (FEP), the estimated return on investment for the pilot CHF disease management program was a savings of $1.08 in medical expenditure for every dollar spent on the program. Adding savings to other payers as well, the return on investment was a savings of $1.15 in medical expenditures per dollar spent on the program. The amount of savings depended upon CHF risk levels. The value of a pilot initiative and evaluation is that lessons for larger-scale efforts can be learned prior to full-scale rollout.

Adult↗

PubMed2006

Promoting excellence in end-of-life care: a report on innovative models of palliative care.

BACKGROUND: Promoting Excellence in End-of Life Care, a national program of The Robert Wood Johnson Foundation, funded 22 demonstration projects representing a wide range of health care settings and patient populations to develop innovative models for delivering palliative care that addressed documented deficiencies in the care of patients and families facing the final stage of life. OBJECTIVE: To determine the practicality (feasibility of development and operation as well as acceptance by stakeholders) of new models of care and to determine the impact of the models on access to, quality of and financing for palliative care. DESIGN: The program cannot report scientifically rigorous outcomes, but the grant-funded projects used a variety of methods and measures to assess acceptance of new models and their impact from the perspectives of various stakeholders, including patients and their families, clinicians, administrators and payers. While it is not possible to aggregate data across projects, the data reported to the Promoting Excellence national program office were used to describe program impact with respect to the practicality of palliative care service integration into existing clinical care settings (feasibility and acceptance by stakeholders), the availability and use of palliative care services (access), quality of care (conformance to patient expectations and accepted clinical standards) and costs of care. SETTINGS AND SUBJECTS: The 22 projects provided services in urban as well as rural settings, in integrated health systems, hospitals, outpatient clinics, cancer centers, nursing homes, renal dialysis clinics, inner city public health and safety net systems and prisons. Populations served included prison inmates, military veterans, renal dialysis patients, Native Americans, Native Alaskans, and African American patients, inner-city medically underserved patients, pediatric patients, and persons with serious mental illness patients. RESULTS: Hosting or adopting institutions sustained or expanded twenty of the 22 models, and feedback from all stakeholders was positive. Project sites developed and utilized new palliative care services and addressed quality through implementation of new standards and clinical protocols. Costs of care, where they could be assessed, were unaffected or decreased for project patients versus historical or concurrent controls. CONCLUSIONS: The 22 Promoting Excellence in End-of Life Care projects demonstrated that by individualizing patient and family assessment, effectively employing existing resources and aligning services with specific patient and family needs, it is possible to expand access to palliative services and improve quality of care in ways that are financially feasible and acceptable to patients, families, clinicians, administrators, and payers.

Feasibility Studies↗

PubMed2002

Cost-effectiveness of gemifloxacin: results from the GLOBE study.

The cost-effectiveness of treatment with oral gemifloxacin versus oral clarithromycin for acute exacerbations of chronic bronchitis (AECB) was evaluated. Economic outcomes were assessed for the Gemifloxacin Long-term Outcomes in Bronchitis Exacerbations study. This prospective double-blind, controlled, health outcomes study compared health, economic, and clinical outcomes after randomized treatment with either oral gemifloxacin or oral clarithromycin for AECB. Base case analysis was performed from the third-party payer's perspective and considered the costs of respiratory tract infection-related medical care. Analysis from the societal perspective also included costs of lost productivity. Treatment effectiveness was measured as the proportion of patients without recurrence requiring antimicrobial treatment following resolution of the initial AECB. Data sources included the outcomes study itself and standard U.S. cost sources. Compared with clarithromycin, gemifloxacin treatment resulted in significantly more patients without AECB recurrence requiring antimicrobial treatment after 26 weeks (73.8% versus 63.8%, p = 0.024). Fewer patients receiving gemifloxacin were hospitalized (5 of 214 patients versus 14 of 224 patients, p = 0.059), and they had less time off from usual activities (8.3 days versus 10.1 days). The mean direct cost per patient receiving gemifloxacin was $127 less than with clarithromycin ($247 versus $374, respectively); mean total costs (direct plus indirect) per patient were $329 less for patients receiving gemifloxacin ($1413 versus $1742). Gemifloxacin dominated clarithromycin in cost-effectiveness analysis. Bootstrap analysis indicated that the probability of gemifloxacin being both cost saving and more effective than clarithromycin is 88% from a payer's perspective and 84% from the societal perspective. Gemifloxacin was more cost-effective, improving AECB outcomes and producing substantial cost offsets compared with clarithromycin.

Anti-Bacterial Agents↗

PubMed2004

The impact of delayed chemotherapy-induced nausea and vomiting on patients, health resource utilization and costs in German cancer centers.

BACKGROUND: Delayed chemotherapy-induced nausea and vomiting (CINV) remains a major adverse effect of cancer chemotherapy. We assessed, under current practice patterns, the occurrence and impact on healthcare resource utilization of CINV in patients receiving emetogenic chemotherapy. An additional aim of this study was to estimate costs imputable to CINV in the German healthcare environment. MATERIALS AND METHODS: This prospective, multi-center, cross-sectional cost-of-illness study was conducted in three hospitals and in three office-based facilities in Germany. Consecutive patients undergoing emetogenic chemotherapy (levels 4 or 5 according to Hesketh classification of emetogenicity) were enrolled. Data were obtained from preplanned chart reviews and from self-administered patient questionnaires. Analysis of direct costs was performed from the perspectives of third party payer (statutory sick fund), provider (hospital) and patients. Indirect costs were assessed on the basis of paid workdays lost. RESULTS: During the 5-day observation period, 134 of 208 chemotherapy cycles observed (64.4%) were associated with at least one episode of nausea or vomiting. More patients experienced delayed than acute CINV (60.7% versus 32.8%), and more patients reported nausea than vomiting (62.5% versus 26.0%). A total of 68 patients (32.6%) utilized healthcare resources due to CINV. The most frequently used resources were rescue medications and outpatient hospital and office physician visits. Only one patient required hospitalization and only three patients lost workdays due to CINV. Average costs imputable to CINV per patient (with or without CINV) per treatment cycle incurred by third party payers and hospital providers were Euro 49 and Euro 48, respectively. Patient or treatment characteristics that were associated with high costs imputable to CINV were as follows: cisplatin-containing regimen; experience of emesis; and presence of delayed CINV. CONCLUSIONS: A substantial proportion of patients continue to experience CINV. This entails not only clinical but also economic consequences, and highlights a continuing need for improved utilization of existing antiemetic agents and for new, more efficacious treatments. The greatest improvements in patient care and potential for cost offset may be realized by preventing delayed CINV.

Antiemetics↗

PubMed2002

Health and long-term care use trajectories of older disabled women.

PURPOSE: I examined health and long-term care use trajectories of a sample of chronically disabled older women eligible for both Medicare and Medicaid by exploring their use data in order to understand and anticipate the increasing demand on the health and long-term care delivery systems as aging female baby boomers reach age 65 and older. DESIGN AND METHODS: A sample of older disabled women in Ohio who completed preadmission review was divided into three groups on the basis of the setting in which they received their initial long-term care services. RESULTS: I was able to establish a long-term care career for the sample members beginning with receiving long-term care in the community, followed by a transition stage in which care was received in the community and in a nursing home, and finally by a stage at which they entered and remained in a nursing home. As the sample members proceeded along their long-term care career and their health and disability status worsened, I found a clear shift in the kind of care needed from hospital and home care to nursing home care. There was also a shift in the major payer, from Medicare to Medicaid. IMPLICATIONS: As the baby boomers age, a much larger number of women will be disabled and need health and long-term care services. For a considerable number of these women, Medicaid gradually becomes the major payer for care, an issue that needs close observation.

Aged↗

PubMed2006

Differences between newly admitted nursing home residents in rural and nonrural areas in a national sample.

PURPOSE: Previous research in specific locales indicates that individuals admitted to rural nursing homes have lower care needs than individuals admitted to nursing homes in urban areas, and that rural nursing homes differ in their mix of short-stay and chronic-care residents. This research investigates whether differences in acuity are a function of differences in resident payer status and occur for both individuals admitted for short stays, with Medicare as payer, and those needing chronic care. DESIGN AND METHODS: We used a representative 10% sample of national resident assessments (Minimum Data Set) for calendar year 2000 (N = 197,589). We conducted statistical analyses (means, percentages, and logistic regression) to investigate differences in Medicare and non-Medicare admissions to facilities in metropolitan and nonmetropolitan areas. RESULTS: Non-Medicare residents admitted to rural nursing facilities have lower acuity scores than non-Medicare residents admitted to metropolitan nursing homes. However, individuals admitted under Medicare were similar in rural and urban areas. IMPLICATIONS: Differences in resident acuity at admission among facilities in different locales were largely a function of lower acuity levels for individuals admitted to rural nursing homes for long-term or chronic care, although differences in Medicare census also played some role in facility-level differences in acuity. Other factors must be explored to determine why this lower acuity occurs and whether higher use of rural nursing homes by less impaired older persons meets their needs and preferences and represents good public policy.

Adolescent↗

PubMed2006

The impact of micro health insurance on Rwandan health centre costs.

While the implications of payment mechanisms for provider behaviour and cost have been amply explored in industrialized countries, there is little empirical evidence from developing countries. This study exploits the opportunities created by a pilot study of micro health insurance with capitation in Rwanda to address this issue. Using cross-sectional data collected in 52 health centres, the paper employs an econometric cost function with payer-specific outputs to assess the cost impact of two provider payment mechanisms: (1) user fees for care paid by the uninsured, and (2) capitation payment paid by informal insurance schemes for the insured. The cost function allows payer-specific marginal and average costs and scale measures to be calculated. Findings point to significant differences in cost between the two payment forms. These may be due to the incentives embodied in the capitation provider payment or the less severe case-mix among insured patients arising from improved access to care for this group, or both. For both payment types there are important short-run economies of scale, which could be exploited through more intensive use of idle resources in health centres.

Community Health Centers↗

PubMed1999

Differences in stakeholder expectations in the outcome of physiotherapy management of acute low back pain.

OBJECTIVE: To compare stakeholder expectations of outcome of physiotherapy management of acute low back pain. DESIGN: Observational design using interviews and questionnaires. SETTING: Practice/workplace. STUDY PARTICIPANTS: The study sample was from South Australia. It comprised 74 physiotherapists randomly selected from professional association listings (49.3% response rate), 121 physiotherapy patients (recruited by participating physiotherapists when attending their first physiotherapy treatment for acute low back pain), 21 general practitioners randomly selected from medical practitioner listings in the metropolitan telephone book (36.2% response rate) and 13 third party payers of a total of 16 available insurers in the metropolitan area (82% response rate). MAIN OUTCOME MEASUREMENTS: Stakeholders reported expectations of outcome at the end of the first treatment session and at the completion of the episode of care. RESULTS: There were differences in expectations between stakeholders, as well as between naive and experienced patients. Overall, patients expected symptom relief at the end of the first treatment. Naive patients decided to return for further treatment based on the relationship established with the therapist, whereas experienced patients also expected some advice on their condition during the first contact. Physiotherapists and referrers expected symptom relief and then long-term management strategies to be provided, and third party payers expected cost-efficient management of the condition and patient satisfaction. CONCLUSION: Physiotherapists need to address potential imbalance of consumer knowledge and foster a quality partnership with their patients on the first visit to physiotherapy. Patients who are in pain may not derive full value from information provided in an untimely manner.

Acute Disease↗

PubMed1990

Physician investment and self-referral: philosophical analysis of a contentious debate.

A new economic phenomenon, in which physicians refer their patients to ancillary facilities of which they themselves are owners or substantial investors, presents a 'laboratory' for assessing philosophers' potential contributions to public policy issues. In this particular controversy, 'prohibitionists' who wish to ban all such self-referral focus on the dangers that patients and payers may receive or be billed for unnecessary or poor-quality care. 'Laissez-fairists', in contrast, argue that self-referral should be freely permitted, with a reliance on personal ethics and internal professional monitoring to guard against abuse. Undue government regulation, they argue, infringes providers' and patients' economic freedom, and stifles the competition that can yield better quality care at lower prices. As this debate features basic values and large amounts of money, it has been marked by rancorous rhetoric, shallow argument, and muddled reasoning. The philosopher's first contribution, therefore, is to expose simplistic and fallacious arguments, whether empirical, conceptual, moral, or legal. Beyond this the philosopher can help to identify the important values at stake and, perhaps, to identify resolutions that honor those values better than the more simplistic answers proffered previously. For abusive self-referral, as distinguished from kickbacks, the author recommends that civil remedies be favored over criminal prohibitions. She suggests that the doctrine of 'bad faith breach of contract' might appropriately be extended into this new area to provide a powerful means by which aggrieved patients and payers can hold physicians personally accountable for abusive self-referrals.

Conflict of Interest↗

PubMed1993

Supporting future surgical innovation. Lung transplantation as a case study.

OBJECTIVE: Using lung transplantation as a case study, this article addressed the problem of supporting innovative clinical surgery in an era of increasing pressures for cost containment. SUMMARY BACKGROUND DATA: After sporadic attempts at lung transplantation during the 1960s and 1970s, its clinical development began in earnest during the early 1980s. As a result of a wide range of incremental advances, the results have improved significantly. The Health Care Financing Administration, however, has not yet issued a national policy covering lung transplants and has left the coverage decision to the discretion of its regional contractors. METHODS: The authors surveyed the major commercial insurers, the Blue Cross Blue Shield Association, and a sample of Medicare intermediaries to evaluate the coverage of lung transplantation. They also interviewed the National Heart, Lung, and Blood Institute and industrial firms about their support for clinical research. RESULTS: Government and industry funding were limited, and the development and assessment of lung transplants have been financed predominantly by academic institutions through cross-subsidization from patient care and teaching funds. The major private payers and Blue Cross Blue Shield decided to cover this procedure in the early 1990s. Coverage decisions by Medicare intermediaries, however, revealed considerable variability. Moreover, the absence of a specific diagnosis-related group for lung transplants had considerable consequences for institutions in all-payer states, in which payments appeared to be considerably lower than the mean costs of a transplant procedure (about $110,000). CONCLUSIONS: This analysis indicated that there was a growing disparity between the increasing demand for outcomes data about new procedures and the limited resources available for supporting the development and assessment of new operations. It this disparity is not addressed, the rate of surgical innovation may be jeopardized, and timely outcomes data may not be acquired. It was concluded that provisional coverage within a predetermined research protocol may be a promising mechanism to remedy this situation, providing timely assessment of new procedures before widespread application.

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

PubMed2003

Prospective medicine: the next health care transformation.

The introduction of science into the practice of medicine in the early 20th century was a transforming event for the profession. Now, breakthroughs in science and know how make it possible to transform care once again and to fix the broken U.S. health care system. To realize this potential, new models of prospective health care must be created and validated. Prospective health care would determine the risk for individuals to develop specific diseases, detect the disease's earliest onset, and prevent or intervene early enough to provide maximum benefit. Each individual would have a personalized health plan to accomplish this. Current knowledge is already sufficient to implement this approach, but there are no effective practice models, delivery systems, and appropriate reimbursement mechanisms. The authors describe the mechanisms of managing care prospectively, describe the components of a personalized health plan, and show how prospective care could relate to a community or group of covered individuals. They conclude by stressing that all interested parties, including academic health centers, insurers, and payers, will need to work together to develop innovative applications of new technologies and appropriate delivery models. At their own institution, pilot programs to foster prospective health care have already begun, and another initiative to develop models to use genomic medicine is also underway. Bipartisan political support will also be needed to help achieve rational reimbursement between providers and payers, so that prospective care can fulfill its promise of being the best cost-effective model to improve the nation's health.

Delivery of Health Care↗

PubMedDate not supplied

A method to risk-adjust rehabilitation outcomes using functional related groups.

In our rapidly changing and increasingly expensive health care environment, payers, patients, and other consumers are beginning to demand that rehabilitation providers demonstrate their value through outcomes data. Although self-assessment is not new to rehabilitation, the instruments and databases at our disposal generally do not fully adjust for severity of disability, health status, or other factors that may affect outcomes. This paper demonstrates a technique using functional related groups (FRGs) to adjust inpatient length of stay and treatment efficiency to reflect relative risk. This paper describes the application of an analytic method and does not involve hypothesis testing. The method uses a simple hand calculator or spreadsheet software to risk-adjust outcomes using FRGs. Steps in the analysis consist of the following: (1) determining FRG categorization for each patient; (2) estimating the expected number of patients in each FRG, given total provider population; (3) comparing the expected with the actual number of patients in each FRG; (4) adjusting length of stay and length of stay efficiency to reflect these differences. The technique described in this paper can be used by any inpatient rehabilitation providers who collect Functional Independence MeasureSM (FIMSM) data and patient diagnostic and demographic data. It is easily updated on an ongoing basis. Without adjustments for risk, outcomes may mislead providers, payers, and other users of the information, and limited resources may be expended in tracking a problem that does not exist. Even small adjustments for severity may shift perceptions regarding provider efficiency and quality.

Confounding Factors, Epidemiologic↗

PubMedDate not supplied

Cost analysis of the Novacor Left Ventricular Assist System as an outpatient bridge to heart transplantation.

Three patients were bridged to heart transplantation with the wearable Novacor Left Ventricular Assist System (Baxter Healthcare Corp., Oakland, CA) (LVAS). Two have been transplanted and discharged. The third patient remains at home. Hospitalization costs, which include the unit room charge, admission profile to the unit, and daily supply charge, were determined for all patients and compared. The patients were transferred from the surgical intensive care unit to a telemetry unit once they were hemodynamically stable. The projected hospitalization costs, if the patients had remained in the hospital, were calculated to determine probable savings for the third party payer. The average period from admission to placement of the Novacor LVAS was 15 days (range, 7-21 days). The average hospitalization cost from admission to time of Novacor left ventricular assist device implant was $2,240/day, and the average hospitalization cost after implant to discharge was $1,570/day. Hospitalization cost savings were $2,632 for the first patient, $5,922 for the second patient, and $132,124 for the third patient, who has not been transplanted. Although the number of patients is small, the daily hospitalization cost was higher before the Novacor LVAS was implanted. This is related to the severity of the disease and the length of stay in a surgical intensive care unit. There also is a significant cost savings for the third party payer, especially if the patient has to wait a significant amount of time before heart transplantation. These are important considerations in this time of managed care.

Ambulatory Care↗

PubMed1996

Health information services technologies.

Increasing demands for provider profiling have led to the growth of health information services units within payers and health plans. An important decision faced by these groups is whether to buy or build the information infrastructure necessary to support the activities of the department. The article offers an overview of a system that was collaboratively designed and built by Blue Cross and Blue Shield of Iowa and the Dartmouth Medical School. A case study illustrating the flexibility of the information system in adapting ambulatory care groups to the fee-for-service payer industry is reviewed.

Ambulatory Care↗

PubMed1998

The incremental cost of second and third ambulatory procedures.

The discount factor applied to payments for second and subsequent ambulatory procedures in a payment system based on ambulatory patient groups (APGs) is important in determining the financial incentives of the system and the adequacy of the payment rates. A 1995 empirical study of data from all ambulatory surgery cases done in acute general hospitals in Maryland suggests that the incremental charges associated with an APG when it is a second procedure APG are about 24% of the charges that are incurred when the APG is the only procedure APG in an encounter. For the third procedure APG, the percentage drops to 16%. This 24% factor is much lower than the discount factor generally used in APG payment systems. The article presents APG-adjusted charges by payer to show differences in resource use by payer. These results will be useful for organizations developing APG-based payment systems for ambulatory surgery or desiring to use APGs for benchmarking purposes.

Ambulatory Surgical Procedures↗

PubMedDate not supplied

A descriptive summary of New Jersey's 1985 burn population.

Data obtained from the New Jersey State Department of Health on the 1985 hospitalized patients with burns and data collected from the National Burn Victim Foundation's standard burn reporting form were analyzed to gather information about the epidemiology of burns. Children (0 to 4 years of age) continue to be the largest percentage of the 0- to 18-year-old age group who sustain burn injuries, and 67% of those injuries are sustained by children under the age of 5. Males accounted for 69% of the total burn population; 58% of admissions were white; 69% of patients were admitted for partial-thickness burns, and 31% were admitted for full-thickness burns; the largest primary payer was third-party payers; and 92% of patients with burns were discharged to home or self-care. Data were also analyzed by examination of selected age groups to determine individual needs of specific groups. An analysis of burn injuries reported to the National Burn Victim Foundation confirmed previous reports that the home is the most likely place for a burn injury to occur and that flame and scald injuries predominate; scald injuries comprise 50% of all sustained burns. Gasoline vapors accounted for 54% of burn injuries caused by flames. The data supported efforts to develop programs that address the needs of the urban child, the 17- to 19-year-old age groups, and the elderly. The information that was collected served to redefine objectives for burn prevention programs.

Accidents, Home↗

PubMedDate not supplied

Quality burn rehabilitation: cost-effective approach.

As funding for health care becomes a national concern, and workman's compensation and private health insurance companies attempt to limit their expenditures in the treatment of the client with burns, it may become the responsibility of the burn specialists to create a cost-effective approach to quality burn rehabilitation. Our outpatient rehabilitation program has taken a cost-effective approach that limits the use of inpatient rehabilitation, emphasizes the burn team guiding the client to a quick functional return to home and work, and concentrates costs for therapy rather than room and board. This cost-effective rehabilitation approach emphasizes an intensive 6-hours-per day, 5-days-per-week outpatient program that begins immediately after discharge. In a 2 1/2-year follow-up of this cost-effective program, the following were identified. (1) A 40% reduction in costs for third-party payers and (2) clients returning to work an average of 4 months after their injury. In the cost-effective rehabilitation approach, 82% of the health care costs are concentrated for therapy. In the traditional inpatient rehabilitation program, room and board costs comprise 57% of the charges. Because it is the responsibility of the burn specialists to educate the health care payers, a program description to implement the cost-effective approach to burn rehabilitation is provided.

Adolescent↗