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PubMed2000

Health technology assessment.

The developing role and use of diagnostic imaging continue to emerge as disease management paradigms are refined and clinical guidelines are employed more often. Health technology assessment, HTA (also known as health care technology assessment), is fundamentally a form of policy research. By formulating effective HTA, the short- and long-term effects of health care technology are studied in a systematic and multidisciplinary way. The fundamental aim of all HTA is to assist those individuals and organizations who stand to benefit from a new health technology (patients), those who will apply the technology (providers), and those who will pay for it (payers) to make better decisions about the technology they utilize by supplying information that is of a high scientific standard and population-based. Effective HTA is especially useful to health care providers, payers, professional groups in health care, manufacturers, political decision-makers and the general public or consumers of health care technology because it represents a process through which effective technology can be identified and ineffective technology can be understood in the context of its limitations. HTA is a multidisciplinary undertaking requiring combined expertise in clinical medicine, epidemiology, biostatistics, bioengineering, health economics, administration, psychology, sociology, ethics and legal science. Additionally, the experiences and opinions of health technology users and consumers of health care (especially patient advocacy groups) are needed to form an overall accurate understanding of the technology under review.

Costs and Cost Analysis↗

PubMedDate not supplied

Alternative cost-effective anesthesia care teams.

Private and public payers are increasingly seeking an overall per-diem or global surgery rates that put hospitals at significant financial risk for anesthesia services. Other payers are demanding deep discounts in anesthesia fees and negotiating global capitation rates that put both hospitals and physicians at risk for all care including anesthesia. This study examines some of the various organizational models for using physician anesthesiologist (MDA) and nurse anesthetist (CRNA) resources most cost effectively and safely. Variations in percentages of these practitioners can be seen in that California reportedly has 47 MDAs for every 10 CRNAs while Michigan has just 6 MDAs for every 10 CRNAs practicing in that more highly managed care environment. Four various anesthesia practice models are described in detail without declaring any one a universal model. The cost per year for MDAs averages $294,000 while the cost per year for CRNAs is less than half as much.

Anesthesiology↗

PubMed2000

Clinical benchmarking for the office practitioner enabled by the online health record

Payer organizations, regulatory entities, and delivery networks are placing increasing pressure on physicians to report aggregate information about their patients and practice of medicine. Historically, clinicians have been ill-equipped to respond to these pressures when their practices have relied upon payer records for clinical information management. Key Industry Drivers: Physicians need specific information from their practices for the purposes of contract management, preventive care, office productivity, and utilization reviews. Value Statement: Clinical data captured at the point of care can support reporting requirements, and supplement or replace laboriously-collected data derived from billing and other administrative systems. Information from the Online Health Record can empower the individual physician to assess what is going on in their practice of medicine, as opposed to being "profiled" by an external entity. We created a secure web-based system that provides access to a clinical data mart, to allow online benchmarking for the individual or office practitioner. Providers used a web-enabled documentation system to document the clinical facts of the encounter. A nightly set of routines extracts data from the online chart into the clinical data mart built in a relational database. The system uses a clinical vocabulary server to map provider-entered strings to normalized clinical concepts. The system loads chart data into a dimensional data model, to simplify data representation and ensure fast query performance. Providers can access their own profiles from a secure web browser.

Journal Article↗

PubMed2000

Telerehabilitation: managed care's new opportunity.

Recent advances in telecommunications technology are leading to new developments in postacute and rehabilitative care. For about $400 per patient and a telephone hookup, physicians and therapists can provide ongoing, direct care to patients at remote clinics or in their homes. The lack of large-scale randomized controlled trials demonstrating clinical and cost effectiveness in rehabilitation and telemedicine has precluded many payers from reimbursing for services. Guidelines for best use do not currently exist, yet the benefits for payers, providers, and patients could be substantial. Telerehabilitation could become an important modality to MCOs seeking to extend the continuum of postacute care to nonclinical settings.

Aged↗

PubMed2000

The managed-care perspective for improving quality.

The role of managed-care organizations (MCOs) is to determine the existence of a benefit and how it is to be covered. Clinical guidelines and evidence-based medicine are critical parts of those decisions, and help drive much of the medical policies of MCOs. The goal is to identify and support medically appropriate and cost-effective interventions, and not cover treatments that do not have those characteristics. This will become increasingly important as more payers move to defined contribution plans, which place added responsibility for care decisions on the medical care consumer. Improving quality, creating consistency, and establishing the credibility of MCOs and their guidelines are imperative for integrating evidence-based medicine into coverage decisions. The ultimate outcome sought by MCOs and payers is improvement of the health of the populations they serve.

Data Interpretation, Statistical↗

PubMed2000

Pros and cons of practice-owned and office-based ambulatory surgery centers.

A detailed feasibility analysis is imperative to ensure the success of a practice-owned ASC. Analysis of the payer mix and the market relating to surgical volume that can be performed at the ASC is imperative. If overbuilding, overequipping, and overstaffing are avoided and the group has adequate volume that can be managed at the ASC, the facility should be a success. Building a practice-owned ASC without an accurate and detailed financial feasibility and payer study can place the endeavor at risk. A well-planned, economically constructed and properly managed ASC will result in an efficient and successful ancillary service for the orthopedic group practice.

Ambulatory Care Facilities↗

PubMedDate not supplied

Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement.

Obstetric risk has important implications for reporting and benchmarking quality in today's managed health care environment. Administrative data, including diagnosis related group (DRG) information collected by hospitals, is used by payers and governmental groups for reimbursement, monitoring quality, and setting financial rates. Obstetric conditions that affect the patient experience are coded but do not often contribute to the overall DRG assignment. This strategy, therefore, may provide comparisons that are misleading to consumers and payers. Additionally, financial rates often do not provide adequate reimbursement for the cost incurred in caring for high-risk patients. Finally, risk prediction strategies have historically been used to both identify vulnerable patients for early management and make more equitable comparisons of groups of patients.

Adult↗

PubMed2001

Capitation: a strategy that could have a future.

Capitation can be successful if hospitals, physicians, and payers share risk to align financial incentives to control costs. Payers need to help hospitals that accept risk to achieve success under managed care agreements. Many failures in hospital capitation might be preventable if hospitals improve internal operations and commit themselves to making the changes necessary for successful risk-based payment.

Aged↗

PubMed2001

The top ten pitfalls in managed care contracts.

Managed care contracts may contain clauses that either have no purpose or have a purpose that the provider does not fully understand. Such clauses may go unrecognized by providers until they are invoked by payers during a contract dispute, often to the detriment of providers. Providers should attempt to exclude or modify such clauses. Providers also should define basic concepts, such as identifying the terms of the contract, determining how disputes might arise over these terms, documenting the agreement struck with the payer, selecting an appropriate dispute-resolution mechanism, and developing a strategy for speedy dispute resolution.

Contract Services↗

PubMedDate not supplied

A survey of pediatric dentists' management of dental caries in children three years of age or younger.

PURPOSE: The purpose of this investigation was to obtain information from practicing pediatric dentists about how they manage caries in children three years of age and younger and the problems they are encountering. METHODS: A survey mailed to a randomly selected sample of 1,000 members of the American Academy of Pediatric Dentists (AAPD) in January of 1997 asked them to: identify the types and extent of caries in the young age group; define and quantify methods used to manage caries; determine the representation of caries among different payer source groups; identify sources of information used in managing caries; and determine the criteria they use for assessing the success of different methods in managing caries. RESULTS: The response rate was 43%. Definitions of techniques of managing caries varied among practitioners, and the use of the methods differed for the different degrees of severity of caries. There was a significant relationship between the percentage of Medicaid in a practice and the percentage of children with caries and pulpal involvement. Personal experience/philosophy was most frequently identified as an important source among factors influencing treatment decisions and sources of information about managing. Criteria most frequently cited to determine effectiveness of treatment were "caries free at recall" (45%) and "stop progress of lesion" (30%). CONCLUSION: Practitioners use a variety of techniques to manage caries in the child < or = 3 years of age. Disease level and payer source factored heavily in their treatment decisions. Practitioners reported interest in receiving information and help from AAPD on the subject.

Adult↗

PubMed2001

Parent management training.

As the estimates of prevalence and cost of mental health problems in our children continue to rise, it is incumbent on our society to have an effective and cost-efficient means to address this health crisis. Consistently, the research literature indicates that PMT offers great promise as an efficacious treatment of conduct-disordered children. There are recent studies of PMT's benefits as a preventive intervention that not only improves children's conduct but also positively affects parent-child relationships, mood, social competence, and school adjustment or performance. Although relatively untested, there are indications that PMT also could play an important adjunctive role in the treatment of internalizing disorders. As a curriculum-driven and didactic form of treatment, PMT is highly adaptable to various treatment and prevention contexts, and from a managed care perspective, PMT's structure allows its costs to be well defined and managed. Despite these positive attributes, however, few clinics systematically offer PMT as a treatment option, and third-party payers have been reluctant to cover its costs. Although it is conceded that much needs to be learned about the scope of PMT's effectiveness and the modifications that are necessary to improve its adaptability to high-risk families, it is proposed that PMT should join the mainstream of broadly available health care provisions for children and their families. This broad inclusion of PMT requires mental health educators to include PMT training as a standard part of provider training, requires that third-party payers include PMT as a covered service, and requires that local and federal governments support the proliferation of PMT in treatment and prevention initiatives.

Adolescent↗

PubMed2000

A clinically detailed risk information system for cost.

The authors discuss a system that describes the resources needed to treat different subgroups of the population under age 65, based on burden of disease. It is based on 173 conditions, each with up to 3 severity levels, and contains models that combine prospective diagnoses with retrospectively determined elements. We used data from four different payers and standardized the cost of most services. Analyses showed that the models are replicable, are reasonably accurate, explain costs across payers, and reduce rewards for biased selection. A prospective model with additional payments for birth episodes and for serious problems in newborns would be an effective risk adjuster for Medicaid programs.

Adolescent↗

PubMed1999

National health expenditures, 1998.

In 1998, national health care expenditures reached $1.1 trillion, an increase of 5.6 percent from the previous year. This marked the fifth consecutive year of spending growth under 6 percent. Underlying the stability of the overall growth, major changes began taking place within the Nation's health care system. Public payers felt the initial effects of the Balanced Budget Act of 1997 (BBA), and private payers experienced increased health care costs and increased premium growth.

Budgets↗

PubMed2001

Hospital registered nurse shortages: environmental, patient, and institutional predictors.

OBJECTIVE: To examine the characteristics of acute-care hospitals that report registered nurse shortages when a widespread shortage exists and when a widespread shortage is no longer evident. DATA SOURCE: Secondary data from the American Hospital Association's Nursing Personnel Survey from 1990 and 1992 were used. The study population was all acute-care hospitals in the United States. STUDY DESIGN: Outcome variables included whether a hospital experienced a shortage in 1990, when many hospitals reported a nursing shortage, or whether a hospital reported a shortage in both 1990 and 1992. Predictor variables included environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using probit analyses. PRINCIPAL FINDINGS: Location in the South, a high percentage of nonwhite county residents, a high percentage of patients with Medicaid or Medicare as payer, a higher patient acuity, and use of team or functional nursing care delivery consistently predicted hospitals reporting shortages both when there was a widespread shortage and when there was no widespread shortage. CONCLUSIONS: Although some characteristics under the direct control of hospitals, such as nursing care delivery model, are associated with their reporting a shortage of nurses, shortage is also strongly associated with broader population characteristics such as minority communities and a public insurance payer mix. Awareness of these broader factors may help inform policies to improve the distribution of nurse supply.

Aged↗

PubMed2001

Telemedicine: follow the money modalities.

Until the late 1990s,e private and public third-party payers generally did not have explicit policies to pay for telehealth services. The Balanced Budget Act of 1997 signaled a significant change in Medicare payment policies opening the door for telemedicine reimbursement. This article traces the development of current Medicare telemedicine payment policies, beginning with the BBA of 1997 and including current medicare payment legislation. Issues related to telemedicine payment by both Medicare and other third party payers are presented; implication for the future, and the role of the nursing community are discussed.

Aged↗

PubMed2002

A review of CHIN initiatives: what works and why.

A Community Health Information Network (CHIN) can generate revenue through multiple avenues and maximize efficiency for participants, including multiple payers, physicians, hospitals, labs, pharmacies, and ancillary providers. This article reviews representative CHIN initiatives over the past decade and identifies key success factors, such as provider adoption and participation in planning, multiple-payer participation, providing key transactions, and incremental implementation.

Community Networks↗

PubMed2002

Developing organizational charity-care policies and procedures.

A lack of standards in healthcare organizations often makes it difficult to consistently define and report charity care. Accurately documenting services provided to patients who are unwilling or unable to pay can be difficult for many organizations. Temple East, Inc., Philadelphia, Pennsylvania, established several policies in an attempt to clarify its charity-care provisions. Among the organization's guiding principles were that all unreimbursed costs of caring for patients who are either uninsured or enrolled in a Medicaid program and all bad debt directly attributable to services to low-income or uninsured patients should be included as charity care. The organization also determined that contractual allowances and disallowances for payers other than government payers should not be included as charity care. Determining clear, unambiguous definitions for several terms related to charity care also helped the organization better track and document its charity-care services--a task that will become increasingly important for hospitals in the future.

Accounting↗

PubMed2002

The economic impact of motor vehicle crashes: the cost of restrained versus unrestrained occupants in South Carolina.

The purpose of our study was to evaluate the difference in hospital charges between restrained and unrestrained motor vehicle occupants. We were also interested in identifying whether a relationship existed between restraint usage and insurance status. The data for this study were collected from two sources. The 1998 and 1999 Crash Outcome Data Evaluation System was used to compare the hospital charges and restraint usage for all motor vehicle crashes in the state of South Carolina. The patient's insurance status was also analyzed. The hospital charges and restraint usage were also compared from one of the state's Level I trauma centers for the year 1999. These data were prospectively collected and retrospectively reviewed. The average inpatient hospital charges for the state of South Carolina were approximately 25 per cent greater or $4500 more per admission for an unrestrained versus a restrained occupant. There also appears to be a relationship between payer status and restraint usage. Medicaid and self-pay patients were least likely to be using a restraining device at the time of a motor vehicle crash. The data from a Level I trauma center showed similar but more dramatic trends. Hospital charges for unrestrained occupants were 87 per cent higher than those for restrained occupants, which translates into a cost difference of $22,358 per hospital admission. This study highlights the significant economic impact of a simple preventative strategy. The cost savings for a single Level I trauma center translate into almost 9.4 million dollars for a single year. There also appears to be a relationship between usage of a restraining device and payer status.

Accidents, Traffic↗