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PubMed2004

Inpatient-outpatient cost shifting in Washington hospitals.

This paper empirically investigates the phenomenon known as "cost shifting" across inpatient and outpatient hospital services. That is, we examine whether, when faced with lower government reimbursement for outpatient services, providers raise inpatient prices for non-government patients (and analogously for lower inpatient government reimbursement). Using a panel of hospitals from Washington State, we find that private, nonprofit hospitals do cost shift across types of services. We also find that a firm's cost shifting behavior differs based on the type government insurance program (i.e., Medicare versus Medicaid). Government owned hospitals do not cost shift with respect to any type of government insurance plan.

Cost Allocation↗
PubMed1998

Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships--HCFA. Proposed rule.

This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: Clinical laboratory services. Physical therapy services. Occupational therapy services. Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. Radiation therapy services and supplies. Durable medical equipment and supplies. Parenteral and enteral nutrients, equipment, and supplies. Prosthetics, orthotics, and prosthetic devices and supplies. Home health services. Outpatient prescription drugs. Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the law. The proposed rule is based on the provisions of section 1903(s) and section 1877 of the Social Security Act, as amended by section 13562 of the Omnibus Budget Reconciliation Act of 1993, and by section 152 of the Social Security Act Amendments of 1994.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1987

Medicaid program; relations with other agencies, miscellaneous Medicaid definitions, third party liability quality control, and limitations on federal funds for abortions--HCFA. Final rule.

These final regulations (1) revise Medicaid rules to reflect current policy on State payment of cost sharing amounts under Medicare Part B "buy-in" agreements; (2) revise and clarify certain Medicaid definitions; (3) remove the requirement that State plans include third party liability quality control reviews as part of the State's Medicaid quality control systems; and (4) provide for limitations on the use of Federal funds for abortion. These final regulations allow States with Medicare Part B buy-in agreements the option of paying cost sharing amounts for Medicaid beneficiaries for those Medicare services that States do not cover in their Medicaid plans. States may pay cost sharing amounts under Medicare Part B buy-in agreements on all, some or none of the Part B Medicare services that are covered in the Medicaid plan. We are revising definitions and clarifying ambiguities in several existing Medicaid regulations. The revisions are to the definitions of private duty nursing services, inpatient and outpatient, inpatient and outpatient hospital services, and other laboratory and x-ray services. We are removing the requirement in our quality assurance regulations that States monitor third party liability errors as a part of their quality control system. Instead, we plan to issue regulations which encourage improved third party liability (TPL) operations by making them an integral component of State Medicaid Management Information System subject to periodic evaluation through systems performance reviews. We are revising the Medicaid regulations to provide for limitations on the use of Federal funds for abortion, in accordance with previously enacted laws.

Abortion, Induced↗
PubMedDate not supplied

[Determinations of hospitalization from psychiatric ER from S. Gerardo hospital in Monza: epidemiological cross-sectional study].

OBJECTIVE: The study aims to identify the predicting factors of hospitalization in patients who come in Emergency Room with psychiatric symptoms. METHOD: Cross-sectional study using data collected by E.R. of S. Gerardo Hospital in Monza from 1st of June 1995 to 31 May 1997. Inclusion criteria were age older than 18 and the need for psychiatric evaluation. The influence on disposition decision of demographic, clinical and service variables were assessed. MAIN OUTCOME MEASURES: Data were collected by a questionnaire designed for the study and administered by a trained psychiatrist. Statistical analysis was performed by univariate analysis and logistic regression. RESULTS: 2076 cases were evaluated. Univariate analysis yielded higher odds of hospitalization for patients between 39 and 48 years of age, unmarried, unemployed, affected by schizophrenia, mood disorders or personality disorders. A linear trend was reported between hospitalization and severity of illness, siucide risk and aggressiveness. While anxiety proved to be a protective factor, hallucination, delusion, lack of insight, psychomotor inhibition, agitation, confusion, destructive behaviour, odd behaviour, abnormal consciousness and previous hospitalization increase inpatient disposition. On Monday and Friday higher frequency of hospitalization was observed. Logistic regression confirm the role of age, symptoms, aggressive behaviour, severity of illness, suicide risk, and among services variables, days of the week. CONCLUSION: Clinical variables proved to be the main predictors of hospitalization, and an important role is played by the availability of outpatients services: hospitalization was more frequent in the days closer the week-end, when the outpatient services are closed.

Adult↗
PubMed1982

Use of illness-related ambulatory physician services in Finland.

The total utilization rate of ambulatory illness-related physician services in Finland is higher in big urban health center areas than in rural areas. When only the health center physician utilization rates were studied the finding was opposite. A notable finding related to the impact of the national health planning were the surprisingly equal average utilization rates of public sector health services (health center physician and general hospital outpatient services combined) in both areas. In fact, use of cheaper public services was greater in rural than in urban areas. The difference in total use rates was almost entirely due to the larger use of more expensive private physician services in urban areas. At present, there is a great pressure for increasing the supply of health center services in urban areas to the same level as in rural districts. One of the fundamental questions seems to be the pricing of the two service sectors--public and private.

Adolescent↗
PubMed2001

Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments concerning the ownership and investment exceptions in paragraphs (c) and (d) and the compensation exceptions in paragraph (e) of section 1877 of the Act. Phase II of this rulemaking will also address comments concerning the reporting requirements and sanctions provided by paragraphs (f) and (g) of the Act, respectively, and include further consideration of the general exception to the referral prohibition related to both ownership/investment and compensation for services furnished in an ambulatory surgical center (ASC), end-stage renal dialysis facility, or by a hospice in section 411.355(d) of the regulations (this exception presently is in force and effect as to clinical laboratory services). In addition, Phase II of this rulemaking will address section 1903(s) of the Act, which extends aspects of the referral prohibition to the Medicaid Program. Phase II will also address comments received in response to this rulemaking, as appropriate, and certain proposals for new exceptions to section 1877 of the Act not included in the 1998 proposed rulemaking, but suggested in the public comments.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

The implementation of Medicare's outpatient prospective payment system and specific concerns for rural hospitals.

The transition to Medicare's new prospective payment system for hospital outpatient services has arguable been the most complex and difficult programmatic change in the history of Medicare (Federal Register, 2002). Concern about its adverse effects led to holding rural hospitals with 100 beds or fewer harmless from the financial consequences of the new payment system for the first three years. However, small rural hospitals were not held harmless from implementing the outpatient prospective payment system (OPPS). Many outside observers felt that small rural hospitals would be ill-equipped to handle the immensity of change required, and that claim denials or delays caused by inaccurate claims submissions might have a disproportionate effect on smaller hospitals. There were also reports about difficulties with the interim payment system that had been designed to ensure small hospitals did not lose money during the first three years. This policy brief describes issues that arose in implementing OPPS during the first years of the program, identifies specific implementation concerns for small rural hospitals, and raises issues that may warrant further research or policy action.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

Community/hospital indicators in South African public sector mental health services.

BACKGROUND: The need to balance resources between community and hospital-based mental health services in the post-deinstitutionalisation era has been well-documented. However, few indicators have been developed to monitor the relationship between community and hospital services, in either developed or developing countries. There is a particular need for such indicators in the South African context, with its history of inequitable services based in custodial institutions under apartheid, and a new policy that proposes the development of more equitable community-based care. Indicators are needed to measure the distribution of resources and the relative utilisation of community and hospital-based services during the reform process. These indicators are potentially useful for assessing the implementation of policy objectives over time. AIMS OF THE STUDY: To develop and document community/hospital indicators in public sector mental health services in South Africa. METHODS: A questionnaire was distributed to provincial mental health coordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels, annual patient admissions to hospitals and annual patient attendances at ambulatory care facilities. The information was supplemented by consultations with mental health coordinators in each of the 9 provinces. Population data were obtained from preliminary findings of the 1996 census. The community/hospital indicator measuring staff distribution was defined as the ratio of staff employed in community settings to all staff, expressed as a percentage. The community/hospital indicator measuring patient service utilisation was defined as the ratio of the annual ambulatory care attendance rate per 100,000 population to the sum of this rate and the annual hospital admission rate per 100,000 population, expressed as a percentage. RESULTS: Of psychiatric public sector staff, 25% are located in community settings in South Africa (provincial range: 11-70%). If hospital outpatient services are included in the definition of ' 'hospital' ', this figure is reduced to 17% (provincial range: 3-56%). In terms of service utilisation, 66% of patient contacts with mental health services occur through ambulatory care services in South Africa (provincial range: 44-93%). DISCUSSION: Community/hospital staff distribution indicates an overemphasis on centralised hospital-based care in most provinces and inadequate hospital care in certain provinces. Patterns of patient service utilisation indicate an over-reliance on central hospital-based services and substantial unmet need. The findings draw attention to problems in information systems for mental health care in South Africa. IMPLICATIONS FOR HEALTH POLICIES: The community/hospital indicators developed for this study form a useful measure for assessing the implementation of mental health policy over time. For the South African context, the community/hospital indicators are a measure of the extent of resource redistribution from hospital to community services and changing patterns of service utilisation over time. Currently, patterns of resource distribution and service utilisation are inconsistent with government policy. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the development of mental health information systems, refining service indicators and improving methodologies for assessing the implementation of mental health policies in service delivery.

Cross-Sectional Studies↗
PubMed2003

[The quality of outpatient services in health facilities in Hidalgo, Mexico, from the users' perspective].

OBJECTIVE: To identify and assess factors associated with the quality of health care in hospital outpatient services within the state of Hidalgo, Mexico, based on a user survey. METHODS: We performed a cross-sectional, comparative, analytical study of 15 public hospitals within the state of Hidalgo, Mexico. The sample, which was made up of 9 936 interviewees (power: 85%; significance level: 95%) was randomly selected among users of outpatient services between July 1999 and December 2000. We looked at the quality of care using a Likert-type scale. The statistical analysis consisted of inconditional logistic regression. RESULTS: The quality of care was perceived as being good by 71,37% of users surveyed and as bad by 28,63%. Poor quality was primarily perceived in institutions belonging to the social security system (39,41% vs. 19,42% in other institutions). Of those surveyed, 84,94% said they were satisfied with the care they received, and 49,2% said they expected to get better care. In all, 16% claimed they would return to the same hospital only because they had no other choice, and 2% said they would never return. A higher educational level and a better income showed a direct association with the perception of poor quality and discontent with the lenghty waiting period (odds ratio [OR]: 2,3; 95% CI: 2,02 to 2,82) and with the physician's discourteous attitude (OR: 4,22; 95% CI: 3,6-4,8). CONCLUSIONS: They main factors that determine poor quality in health care, according to users, are lengthy waiting times before being ushered in, incomplete physical examination and diagnosis, difficulty of getting an appointment, and poor treatment on the part of services staff.

Adult↗
PubMed1999

Vulnerability of rural hospitals to Medicare outpatient payment reform.

Because the Balanced Budget Act (BBA) of 1997 requires implementation of a Medicare prospective payment system (PPS) for hospital outpatient services, the authors evaluated the potential impact of outpatient PPS on rural hospitals. Areas examined include: (1) How dependent are rural hospitals on outpatient revenue? (2) Are they more likely than urban hospitals to be vulnerable to payment reform? (3) What types of rural hospitals will be most vulnerable to reform? Using Medicare cost report data, the authors found that small size and government ownership are more common among rural than urban hospitals and are the most important determinants of vulnerability to payment reform.

Aged↗
PubMed2005

Attenuation of racial differences in health service utilization patterns for previously uninsured children in the Delta.

CONTEXT: A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers. PURPOSE: The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs. METHOD: General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed. FINDINGS: Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services. CONCLUSIONS: Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Black or African American↗
PubMed1963

Ambulatory service.

Explore the source record for details and available documents.

Computer Systems↗
PubMed1995

Estimating the cost of outpatient hospital care.

Hospital services can be divided into inpatient, outpatient and non-patient areas; outpatient care can be further subdivided into emergency room care, general and special clinic care, day procedures and non-admitted day/night care. Using 1992-93 Statistics Canada data on expenditures and outpatient activity from the Part One form for 29 Alberta hospitals, we estimated the average cost of each of the four outpatient areas. The estimated cost per visit was $183 for clinic visits, $166 for day/night care, $69 per emergency visit and $627 per day procedure. These estimates can be used in cost-effectiveness studies and, if supplemented with outpatient case weights and volumes, in provincial funding systems.

Alberta↗
PubMed1996

Listening to patients in the National Health Service: a selective review of literature on patients' views about outpatient services in British hospitals.

An increased emphasis on quality assurance in the National Health Service (NHS) became evident in the literature related to health following the Government's White Paper, "Working for Patients" (1989) and the Patients' Charter (1991). The latter included specific quality standards to which purchasers and providers of health care made a commitment. This review of published and un-published (grey) literature concentrates on patient views about outpatient services in British hospitals, with special emphasis on the role of nurses. Findings indicate central emphasis on easily measurable factors, such as waiting times in outpatient departments and comparative neglect of more qualitative aspects, which may be of greater importance to patients. Specific attention has been given to exploring the role of nurses working in the outpatient department, which appears to be under-researched, based on this selective literature review.

Health Services Research↗