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PubMed1986

Volatility and opportunity: industry forecast.

Although hospitals have grown and prospered by "doing good," that purpose no longer is the only consideration in health care decisions. Business and the federal government now play key roles in controlling costs, and the once orderly prepayment industry is now a tangle of competitive interests. For the next few years, economic considerations will force quality-of-care issues to the background. In fact, until the current malpractice crisis, which causes physicians to practice defensive medicine, is resolved, it is unlikely that "doing good" will be the dominant concern. The future does not, however, hold greater and stiffer economic competition as far as one can see. Payers will be able to wring concessions from hospitals for only so long. When patient care is jeopardized, payers then will loosen the purse strings, and hospitals will return to a balance between "doing good" and "at what price".

Economic Competition↗

PubMedDate not supplied

The next generation of managed mental health care.

The rise in mental health claims and the tremendous expansion of psychiatric facilities and services have put payers and providers alike on the defensive. Payers cut benefits, while providers rush to justify even clearly needed care. The venturesome in both camps will be intrigued by General Telephone of California's comprehensive, managed mental health care program, combining the PPO concept with provider risk and strong case management, as described by the authors, Vice Presidents of Preferred Health Care, Ltd.

California↗

PubMed1987

Forecasting hospital reimbursement.

The changes in reimbursement to hospitals by third party payers make it essential for hospital administrators to forecast their hospitals' reimbursement potential. Although models have been developed to predict and maximize census, forecast future demand for hospital care, and forecast the revenue budget, none of the models addresses how the physician directly affects the hospital reimbursement potential through office practice admissions. This study analyzes the admitting physician's patients by third party payer and presents a method to assist in using a physician's past hospital admissions to forecast a hospital's admissions and reimbursement potential.

Data Collection↗

PubMedDate not supplied

The erosion of physician-patient privilege and patient confidentiality.

With the proliferation of third party payers for health care who exercise utilization management, there has been an erosion of the physician-patient privilege and patient confidentiality. The kinds of medical information obtained by third party payers under the guise of claims administration violate the spirit if not the actual laws pertaining to physician-patient communication. It presents three episodes involving the first author in which that communication was violated by third parties administering health care benefits. Recommendations are made to protect that confidentiality in this era of increasing cost management.

American Medical Association↗

PubMed1989

Privacy Act of 1974; systems of records--HCFA. Notice of proposed new routine uses for existing systems of records.

One of the top priorities of the Department of Health and Human Services is to assure high quality and effective health care while pursuing strategies to contain or moderate health care costs and Medicare program expenditures. One such program to limit Medicare programs expenditures was the Medicare Secondary payer (MSP) provisions (42 U.S.C. 1395y(b)). The purpose of this routine use is to enable HCFA and other "entities responsible for payment" to engage in exchanges of information concerning primary or secondary responsibility for a Medicare beneficiary's health care expenses. This notice is not the basis for a mandatory reporting requirement for "entities responsible for making payment" as required by 42 U.S.C. 1395y(b). Currently no statute mandates this type of exchange of information, therefore, these exchanges of information are strictly voluntary. The Health Care Financing Administration (HFCA) is amending systems notices for (1) Carrier Medicare Claims Records HHS/HCFA/BOP No. 09-70-0501; (2) Health Insurance Master Record HHS/HCFA/BOP No. 09-70-0502 and (3) Intermediary Medicare Claims Records HHS/HCFA/BPO No. 09-70-0503, to add a new routine use. The proposed routine use will enhance our capability for identifying Medicare Secondary payer situations where Medicare can assume a position of reduced liability due to the presence of other entities responsible for making primary payment in accordance with 42 U.S.C. 1395y(b).

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

PubMed1999

Consumer protection and the HMO backlash: are HMOs to blame for drive-through deliveries?

This study used patient discharge data from New Jersey to examine differences in length of stay for normal, uncomplicated deliveries between patients in health maintenance organizations (HMOs) and those not in HMOs. The percentage of one-day stays increased from less than 4% for all payers in 1990 to 48.1% for HMO patients, and 31.5% for non-HMO patients in 1994. Controlling for other factors, the odds of an HMO patient staying one day were nearly twice as great as a non-HMO patient by 1994; for all patients, regardless of payer, the odds of a one-day stay in 1994 were more than 18 times the odds of a one-day stay in 1990. The strong secular trend suggests that legislation and regulations should be targeted at particular policies rather than insurers.

Adult↗

PubMed1999

Successful contracting depends on optimal retail pricing.

Retail price structures are a critical part of the managed care contracting process because payers use local and national charge norms to compare hospitals and to determine negotiating targets. To successfully negotiate managed care contracts, and to be able to offer sensible discounts to payers that require them, a healthcare organization needs to determine its retail prices relative to the marketplace. By measuring their charge structure's variance from those of other providers in the same market, healthcare organizations can ensure that their retail prices are competitive.

Contract Services↗

PubMed1996

Back to the Future for Clinical Oncology.

Dear Colleague: I remember, but just barely, what it was like to practice medicine in the first half of this century. My Dad was a general practitioner in a very small farming community in central Illinois, with a hospital of six beds and a trusting clientele. His patients thought he knew how to do everything: deliver babies, set broken bones and take out an appendix. He was an advocate for his patients, not for an HMO or an insurance company. He derived great satisfaction from his practice and was comfortable in this role, up to a point, but knew that he frequently needed the help of specialists from Decatur, St. Louis, and the Mayo Clinic. As his experience and practice evolved, and as medicine itself changed, referrals became a sign of good practice and not an indication of weakness or inadequacy. Some doctors in our town continued to do more than they should have and resisted the trend, and their patients, many with blind faith in their doctor, suffered for it. Clearly, there were economic as well as emotional factors that contributed to this reluctance to ask for help. Clinical oncology is facing much the same situation today. Scientific and economic forces are revolutionizing medicine, but not always in compatible directions. Practice and research have evolved to the point where old patterns of practice are no longer optimal. Few cancer patients can be managed without the input, advice, and even direct involvement of specialists from sister disciplines. Thus, multimodality management of cancer patients is now the norm rather than the exception. At the same time, strong economic forces are dictating a movement in the opposite direction, undermining the strength of traditional academic centers and limiting choices, streamlining patient evaluation, and creating "pathways" to standardize patient management. Who should be setting the course for the cancer patient? We agree that it should not be a clerk at the other end of the phone at the HMO, a computerized practice manual, or even the gatekeeper, who watches his or her capitated bottom line with great nervousness. It should be the physician(s) best able to evaluate the alternatives and communicate these choices to the patient and family. Often it is not possible for a solo physician to make these choices in isolation, particularly when the decisions involve multiple specialties and multimodality therapies. At presentation, many primary cancers now require an integration of the opinion of more than one specialist, and increasingly this integration occurs before surgery. Breast, lung, and prostate cancer, three of our most common diseases, illustrate this point with growing clarity. While less convenient for the doctor, and perhaps less efficient than the "old style" of practice, multimodatity disease center clinics offer significant advantages both to the patient and to the research effort, and are here to stay. Certainly for the payer it is faster and cheaper to have one doctor do it all, but I doubt that the results will be as good. Obviously not all patients need this cooperative approach. It would waste good physicians' time to require that all patients be seen by a radiotherapist, surgeon, and medical oncologist or pediatric oncologist. The specific circumstances may clearly dictate a simple approach and an uncomplicated decision, particularly in dealing with metastatic solid tumors, or at the other extreme, in managing easily resectable, low-risk tumors. However, even here, optimal management of local disease or of potentially resectable metastases may require consideration of an expanded series of options. Thus, all cancer specialists need to be aware of the potential of their colleagues to contribute to disease management. ellipsisWhich brings us to the reason for this journal. The editorial board members of The Oncologist hold the belief that the various subspecialists in oncology should share the same information base and read from the same journal. We believe that cancer specialists should resist the trend to capitulate our responsibilities in disease management to payers, gatekeepers, and hospital administrators. It is up to us to defend the patient's turf and to assure that the patient has an advocate. In order to do so, we will have to be united and fully informed. In this journal, we hope to put the best and latest information on cancer management before our readership, to prepare them for the future, and to do their best as a team for every patient. To this end, we hope to challenge the reader to understand what is new and better, and to let you glimpse the future, not only in terms of research, but also in terms of new team approaches to disease management. We hope to explore how cancer medicine could be and will be practiced as we pass through the economic revolution and return to the future.

Journal Article↗

PubMed1999

Practical implementation of globally priced episodes of care: lessons learned from Oxford's specialty management program.

Globally priced episodes of care afford payers a more efficient method of allocating risk and simultaneously accommodating the now permanent demand for choice and access at the point of service. Foreseeing the trend away from capitated delivery systems, in April of 1996. Oxford Health Plans began to invest considerable resources to implement global fees. When Oxford ran afoul of Wall Street and New York State insurance regulators (for reasons unrelated to the subject of this article), it was forced to abandon the new program. For the growing number of payers interested in pursuing similar contracting strategies, this article may serve as a useful source of information.

Capitation Fee↗

PubMed1999

A decision technology system for health care electronic commerce.

Mounting costs have escalated the pressure on health care providers and payers to improve decision making and control expenses. Transactions to form the needed decision data will routinely flow, often electronically, between the affected parties. Conventional health care information systems facilitate flow, process transactions, and generate useful decision information. Typically, such support is offered through a series of stand-alone systems that lose much useful decision knowledge and wisdom during health care electronic commerce (e-commerce). Integrating the stand-alone functions can enhance the quality and efficiency of the segmented support, create synergistic effects, and augment decision-making performance and value for both providers and payers. This article presents an information system that can provide complete and integrated support for e-commerce-based health care decision making. The article describes health care e-commerce, presents the system, examines the system's potential use and benefits, and draws implications for health care management and practice.

Commerce↗

PubMedDate not supplied

Health care trends, Part 2. The new health care team. Panel discussion.

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.

Community Participation↗

PubMed1999

Is hospital capitation DOA?

The growth of hospital capitation has been slow because most hospitals have not reached their "capitation threshold." Financial pressure at this threshold compels a hospital to implement cost management methods to allow it to potentially profit from capitation. In addition, most markets have not provided payers with adequate incentives to share risk. Conditions that will drive payers to adopt hospital capitation include true integration of care delivery systems and information systems, sustained medical losses, and strong market position of hospitals.

Capitation Fee↗

PubMed1999

DRG-based per diem payment system matches costs more accurately.

Some managed care organizations use the DRG hospital payment method developed for Medicare to set case rates. Unfortunately, when such a method is used in a risk-sharing arrangement, hospital and physician incentives are misaligned. Hospitals and payers would benefit from using a hospital reimbursement model that calculates inpatient per diem payments for medical and surgical cases by classifying DRGs in tiers and ranking the tiers according to how resource-intensive they are. DRGs provide the means for a rational classification system of per diem rates that recognizes cases where the expected resources are going to be higher or lower than the average per diem amount. If payers use per diem rates that are weighted according to a DRG classification, hospital payments can correlate closely with the actual costs per day for a specific case, rather than an average for all surgical or medical admissions.

Blue Cross Blue Shield Insurance Plans↗

PubMed1999

Effect of insurance on prescription drug use by ESRD beneficiaries.

In this article the author reviews the prescription drug coverage policy in the Medicare End Stage Renal Disease (ESRD) program and examines the relationship between secondary insurance status and the number of medications prescribed for dialysis patients who had Medicare as their primary payer. Negative binomial models were used to examine this relationship. Findings in this study indicate that the number of secondary payers has a significant impact on the number of prescription drugs received by Medicare ESRD patients. Further research is needed to determine whether Medicare beneficiaries without secondary insurance are obtaining fewer prescriptions than needed or if those with greater coverage are obtaining more than needed.

Adult↗

PubMedDate not supplied

Topical issues in the treatment of rectal cancer: economic and organizational aspects of concomitant radiochemotherapy.

Concomitant radiochemotherapy in patients with locally advanced rectal carcinoma has been shown to be useful in improving local control and survival in operated patients and in favoring sphincter preservation when administered before surgery. Together with the search for less toxic combinations, cost-analysis of radiochemotherapy has become topical also in consideration of new generation drugs. In this study the analysis was carried out by comparing the costs for 4 different combined modalities in the dual perspective of the payer (the National Health Service) and the provider (the Hospital). Based on their characteristic of treatment and innovative aspects, the following combinations were examined: external beam radiotherapy (ERT) 50.4 Gy + 5FU bolus; ERT 50.4 Gy + 5FU protracted infusion; ERT 50.4 Gy + 5FU continuous infusion, week 1 and 5; ERT 50.4 Gy+ Tomudex bolus. Costs were evaluated based on the frequency and type of specific services provided in therapeutic protocols: the positioning of central venous catheter, time of stay in day-hospital or hospital ward and the cost of drugs. Calculations were carried out based on an "ideal" patient of 1.7 sqm body surface. Costs were based on out patient rates, DRGs and the official drug list valid to September 1999. As for day-hospital costs afforded by the payer it is observed that the most expensive combinations are bolus and continuous infusion followed by protracted infusion; Tomudex, is the most economic. As for hospital costs afforded by the provider, it is observed that the most expensive combination is continuous infusion followed by protracted infusion, bolus administration and Tomudex. In conclusion, doctors are increasingly involved in the economic and organizational aspects of therapeutic decisions; however, the patient's needs should be kept in mind; apart from the therapeutic benefits, lower toxicity and ready use of treatments are amongst the patient's needs. The analysis of the patient's satisfaction is still lacking suitable means of evaluation, however it should be defined and carefully studied for an exhaustive evaluation of the impact of combined modality therapy.

Antimetabolites, Antineoplastic↗

PubMed1999

RBRVS--1999 update.

Medicare RBRVS has become widely used as a standard for physician fee scales by both traditional health insurance plans and managed care organizations. There are significant variations in the way RBRVS has been adapted by these private payers. These variations, when combined with annual changes Medicare has made to the underlying components of RBRVS, may result in unintended and unexpected increases in physician payments. To avoid surprises, payers using RBRVS-based fee scales need to carefully evaluate the overall impact of annual RBRVS modifications on their delivery systems.

Economics, Medical↗

PubMed1999

The effect of a copay increase on pharmaceutical utilization, expenditures, and treatment continuation.

OBJECTIVE: No research has evaluated the impact of an increase to a copay that is reflective of today's healthcare market. This study examined the effect of an increase from a $10 to $15 copay for brand drugs on key pharmaceutical utilization measures, including participation rates, treatment continuation, and expenditures, in an adult population. STUDY DESIGN: A quasi-experimental, pre-post design with control group was used. PATIENTS AND METHODS: Two different employer plans implemented an increase from $10 to $15 for brand copays in January of 1997. The utilization and expenditures of these plans were compared with those of a control group with a constant brand copay of $10 for 6 months preceding and 6 months following the copay increase. RESULTS: When other predictor variables were controlled for, the copay increase was not associated with a statistically significant difference in overall utilization compared with the control group, although brand utilization was significantly lower in the copay group. Savings to the payer were substantial, and resulted primarily from cost-shifting, reduction in brand utilization, and an increase in the generic fill rate. The rates of continuation with chronic medications in the 6 months following the copay increase were not reduced in the copay group compared with the control group. CONCLUSION: A copay increase can provide substantial savings to a payer without being a major deterrent to overall utilization or resulting in discontinuation of chronic medications.

Adult↗

PubMed2000

Telemedicine can lower costs and improve access.

Communications technology is being used increasingly for telemedicine applications to improve access to medical care in rural areas. The most cost-effective applications are those that are paid for by insurers, such as the use of telemedicine for radiology, prisoner health care, psychiatry, and home health care. Other applications enhance access to care but are not cost-effective because third-party payers do not pay for related costs for professional fees or the implementation of the technology. Before implementing telemedicine programs, healthcare providers should determine whether they would receive a reasonable return on investment by evaluating all associated costs and estimating the amount of payment they can expect. As the use of telemedicine services increases, it is expected that third-party payers will pay for more of these services to control medical costs.

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