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At least 1,153 records · Page 64Linked to original sources

PubMed2002

Pregnancy-associated mortality at the end of the twentieth century: Massachusetts, 1990-1999.

OBJECTIVES: 1) to report Massachusetts pregnancy-associated mortality ratios (PAMRs) and maternal mortality ratios (MMRs) from 1990 to 1999 and pregnancy-related mortality ratios (PRMRs) from 1995 to 1999; 2) to identify disparities in PAMRs by race and Hispanic ethnicity, payer at delivery, age, and age by medical and injury cause of death; 3) to report distributions of pregnancy-associated deaths by cause, preventability, and timing in relation to pregnancy. METHODS: Pregnancy-associated deaths from 1990 to 1999 were identified using enhanced methods, including linkage of vital records. Preventability and pregnancy relatedness were determined by case review (1995-1999). Trends in ratios and aggregate PAMRs by key characteristics were calculated. RESULTS: The 10-year PAMR and MMR were 27.2 and 3.3 per 100,000 live births, respectively, with no significant changes from 1990 to 1999. The PRMR was 6.1 for 1995 to 1999. The leading cause of pregnancy-associated death was homicide. The PAMRs for black non-Hispanic and Hispanic women were 3.1 and 1.8 times higher than that for white non-Hispanic women. The PAMR was 3.2 times higher for women with public than with private payers and 3.4 times higher among women age 40 to 44 than among women age 25 to 39. The injury PAMR for women younger than 25 was 3 times higher than it was for women age 25 to 39. Injuries caused one-third of pregnancy-associated deaths. Fifty-four percent of deaths from 1995 to 1999 were deemed preventable. CONCLUSIONS: Pregnancy-associated deaths are rare, yet many are preventable. Public health prevention strategies should extend beyond the traditional postpartum period and address disparities for black non-Hispanic and Hispanic women, low-income women, older women for medical causes, and younger women for injury causes.

Adult↗

PubMed2002

Economic evaluation of orthoptic screening: results of a field study in 121 German kindergartens.

PURPOSE: The purpose of this study was to analyze the cost-effectiveness of an orthoptic screening program in kindergarten children. METHODS: An empiric cost-effectiveness analysis was conducted as part of a field study of orthoptic screening. Three-year-old children (n = 1180) in 121 German kindergartens were screened by orthoptists. The number of newly diagnosed cases of amblyopia and amblyogenic factors (target conditions) was used as the measure of effectiveness. The direct costs of orthoptic screening were calculated from a third-party-payer perspective based on comprehensive measurement of working hours and material costs. RESULTS: The average cost of a single orthoptic screening examination was 12.58 Euro. This amount consisted of labor costs (10.99 Euro) and costs of materials and traveling (1.60 Euro). With 9.9 children screened on average per kindergarten, average labor time was 279 minutes per kindergarten, or 28 minutes per child. It consisted of time for organization (46%), traveling (16%), preparing the examination site (10%), and the orthoptic examination itself (28%). The total cost of the screening program in all 121 kindergartens (including ophthalmic examination, if required) was 21,253 Euro. Twenty-three new cases of the target conditions were detected. The cost-effectiveness ratio was 924 Euro per detected case. Sensitivity analysis showed that the prevalence and the specificity of orthoptic screening had substantial influence on the cost-effectiveness ratio. CONCLUSIONS: The data on the cost-effectiveness of orthoptic screening in kindergarten may be used by such third-party payers as health insurance or public health services when deciding about organizing and financing preschool vision-screening programs.

Amblyopia↗

PubMed2003

Navigating payment pitfalls in managed care.

Healthcare providers need to identify and address payment problems relating to denied or underpaid claims. Before contract renegotiation, providers should identify the total dollar amount of claims that are denied or underpaid for each payer. Providers should choose managed care contract information systems that can grow with the hospital's managed care volume. Providers should identify all underpayment problems before negotiating a settlement with a payer.

Accounts Payable and Receivable↗

PubMed2003

Best practices for preempting payment denials.

Limiting inpatient claims denials requires a combination of data, processes, and people, including: Systems that support collecting correct payer data; Creative processes to prevent denials in high-denial areas; Compliance with payer protocols; Enhanced front-end staffing.

Benchmarking↗

PubMed2003

Exploring the relationship between inpatient hospital costs and quality of care.

This research explores the potential benefit of improving the clinical quality and reducing the cost of inpatient care using administrative data to inform or restrict provider choice. Cost and quality measures derived from this source are already available to purchasers, payers, and consumers in support of insurance products designed to provide financial incentives for consumers to seek high-quality, low-cost care. It will be important to further refine the clinical and cost data to take into account measurable differences in the severity of illness of patients, and to acknowledge that some of the differences in cost or quality variation among hospitals may not be captured despite such refinements. Medicare cost report data is merged with Uniform Hospital Discharge Abstracts to identify the additional direct cost of patients experiencing 1 of 6 poor clinical outcomes, or admissions for ambulatory care sensitive conditions, or selected surgical procedures at low volume hospitals. Variability in case mix-adjusted cost per case among community and teaching hospital groups is also quantified; measurable quality differences between low cost and other hospitals in each group is described. Our results suggest that, despite implementation challenges, purchaser and payer initiatives that encourage consumers to seek lower cost inpatient care without sacrificing clinical quality are worth pursuing.

Consumer Behavior↗

PubMed2003

Tactics for thwarting silent PPO activity.

Silent payers can be difficult to detect, and their payment practices can drastically affect a hospital's bottom line. An audit approach to payment problems can uncover silent PPO activity. Information from the audit can be used to negotiate a settlement for the unpaid amount. Contracts with payers should include specific language that protects against silent PPO activity.

Contracts↗

PubMed2003

The New England Healthcare EDI Network.

The New England Healthcare EDI Network (NEHEN) is a collaborative of providers and payers in eastern Massachusetts that created, manages, and operates a shared insurance EDI infrastructure. NEHEN currently has 12 provider and three payer members, and supports over 1,000,000 insurance EDI transactions per month. This paper describes the philosophies that define the NEHEN business model and discusses its governance structure, technology, operational issues associated with its implementation, and its current status, along with lessons learned from the NEHEN undertaking.

Community Health Planning↗

PubMedDate not supplied

Clinical and fiscal outcomes of utilization review.

Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.

Case Management↗

PubMed2004

Changing views about "usual charges".

The OIG's new definition of "usual charges" could have a significant impact on payment rates for a hospital's services. Traditionally, "usual charges" has referred simply to non-discounted rates maintained in a hospital's charge description master. The OIG's definition of the term includes discounted rates that a hospital negotiates with commercial payers. If the OIG's definition is adopted, payers may attempt to apply it, thereby complicating rate setting negotiations and monitoring of contract compliance.

Aged↗

PubMed2004

Redefining competition in health care.

The U.S. health care system is in bad shape. Medical services are restricted or rationed, many patients receive poor care, and high rates of preventable medical error persist. There are wide and inexplicable differences in costs and quality among providers and across geographic areas. In well-functioning competitive markets--think computers, mobile communications, and banking--these outcomes would be inconceivable. In health care, these results are intolerable, with life and quality of life at stake. Competition in health care needs to change, say the authors. It currently operates at the wrong level. Payers, health plans, providers, physicians, and others in the system wrangle over the wrong things, in the wrong locations, and at the wrong times. System participants divide value instead of creating it. (And in some instances, they destroy it.) They shift costs onto one another, restrict access to care, stifle innovation, and hoard information--all without truly benefiting patients. This form of zero-sum competition must end, the authors argue, and must be replaced by competition at the level of preventing, diagnosing, and treating individual conditions and diseases. Among the authors' well-researched recommendations for reform: Standardized information about individual diseases and treatments should be collected and disseminated widely so patients can make informed choices about their care. Payers, providers, and health plans should establish transparent billing and pricing mechanisms to reduce cost shifting, confusion, pricing discrimination, and other inefficiencies in the system. And health care providers should be experts in certain conditions and treatments rather than try to be all things to all people. U.S. employers can also play a big role in reform by changing how they manage their health benefits.

Delivery of Health Care↗

PubMed2004

Silent PPOs... are they still a problem?

Silent preferred provider organizations (PPOs) are insurance payer arrangements that offer patients discounted provider fees without providing incentives for them to access the providers' services. These schemes take millions of dollars annually from the pockets of physicians and other health care providers. Learn how to spot a silent PPO and keep your payers on the straight and narrow.

Consultants↗

PubMed2004

Two numbers you need to know.

By examining two numbers--managed care denial and recovery rates--hospitals can assess the effectiveness of their denial management efforts and payer performance and best focus efforts on payer contract compliance to achieve prompt payment.

Contracts↗

PubMed2004

Language barrier leads to the unnecessary intubation of trauma patients.

Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. A 9-year retrospective review was performed using the National Trauma Registry for The American College of Surgeons (NTRACS) database. We evaluated patients intubated on arrival to the trauma center and remaining intubated for less than 48 hours. Deaths were excluded. Patients who typically speak English were compared with patients who typically speak Spanish. Mechanism of injury (MOI), hypotension during resuscitation (HDR), illicit substance use, alcohol use, mean Glasgow Coma Score (GCS), mean Injury Severity Score (ISS), payer source, and hospital cost were compared. Forty-nine per cent and 38 per cent of Spanish and English speaking individuals, respectively, were intubated for less than 48 hours (P = 0.072). MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.

Adult↗

PubMedDate not supplied

Prompt pay statutes for physicians' billing claims: an imperfect remedy for a systemic problem.

Physicians are losing millions of dollars per year from delayed and wrongfully denied claims. Class actions provide for certain forms of prospective relief but do not cover physician losses from payers' vexatious conduct. This article examines the effect of state prompt pay statutes and recent amendments to ERISA regulations on curtailing payer payment abuses. The article discusses the strengths and weaknesses of the statutes, as well as strategies for effectively using the statutes for the benefit of physicians.

Accounts Payable and Receivable↗

PubMed2004

Artificial neural network in pharmacoeconomics.

Pharmacoeconomics research identifies, measures, and compares the costs (resources consumed) and consequences of medical products and services, where at least one of the compared alternatives is pharmacotherapy. Pharmacoeconomics has been designed to enable the decision maker to identify the preferred choice among existing alternatives. The decisions are often important for the patients' lives on the one hand, and for payers on the other (where the payer is understood as the institution responsible for financial resources allocation). One of the most commonly used types of pharmacoeconomic analysis is cost-effectiveness analysis. Two different alternatives can be compared using cost-effectiveness analysis if only their medical and clinical consequences could be measured in similar units (clinical or physical parameters). The aim of the project is to use an artificial neural network (ANN) for medical effect prediction, which could help in the extrapolation of pharmacoeconomic analysis' results. To depict neural data analysis tools, a database containing 100 non-small cell lung cancer (NSCLC) patients in non-operative IIIB and IV stage has been used. Each patient was described using 30 factors (i.e. sex, age, anticancer drugs dosage) and, as an output value, the expected survival time was established. The role of the ANN system was to predict the patient's survival time based on the above mentioned information. Binary values were tested as outcomes. Positive values (coded as 1) meant that patient survival time would be equal to or longer than 35 weeks. Negative values (coded as 0) meant that the patient survival time would be shorter than 35 weeks. Binary values were obtained using a threshold, which based on the mean survival time of patients derived from literature. Back-propagation as well as fuzzy-logic neural networks were applied. A 10-fold cross validation method was used to obtain the appropriate models. Final results were compared with the generic, logistic regression-based model. The best prediction score of the ANN model was 82%; higher than logistic regression prediction rate.

Antineoplastic Agents↗

PubMed2005

Treatments for mild-to-moderate recalcitrant plaque psoriasis: expected clinical and economic outcomes for first-line and second-line care.

The cost effectiveness of treatments for psoriasis has been evaluated previously by several different investigators. Such evaluations should be updated as new products or data become available. To this end, a comparison of expected treatment-related clinical and economic outcomes is undertaken from the payer perspective using a disease-intervention model, decision analyses, and newly emergent information. The model is based on academy guidelines and recommended clinical practice. Model inputs (clinical and cost data) are culled from the medical literature and advisory clinical assessment surveys. Comparable therapies are various topical pharmacotherapies and phototherapies, including the 308-nm excimer laser (XTRAC, PhotoMedex, Montgomeryville, PA). Analytic results indicate that clinical and economic outcomes are influenced by treatment selections but are muted by the rotational nature of treatment regimens. Multiple analyses are required to reveal individual product performance. On the basis of these analyses, the addition of the 308-nm excimer laser to the rotational mix of treatments commonly utilized as second-line therapies for mild-to-moderate plaque psoriasis is expected to add incremental clinical benefit for patients without incremental cost for payers, because the laser can replace both more costly and less costly alternatives for appropriately selected patients who require a different therapeutic modality to maintain or improve their responsiveness.

Administration, Topical↗

PubMedDate not supplied

Clinician-patient E-mail communication: challenges for reimbursement.

Clinicians are rapidly gaining experience with online clinician-patient consultation, and more tools are becoming available to support these efforts. In addition, we now have evidence that using electronic communication is cost-effective to payers and appealing to patients and providers. At present, there appear to be few barriers to the adoption of these solutions for practices that use other online services. Security concerns can easily be overcome by using programs described in this commentary. Larger and longer studies that evaluate the benefits and cost savings in more detail may help convince other payers and providers of the utility of the Web-based programs. More studies are needed to understand the effect of dinician-patient electronic communication on the costs of caring for chronic illness. When these solutions also include support tools, such as electronic prescribing, which could improve patient safety and quality of care, they should be encouraged. In their article entitled, "Electrons in Flight-Email between Doctors and Patients," Delbanco and Sands postulate that the future of e-communication in medicine will be integrated with a patient-controlled health record and will include secure synchronous and asynchronous communication, video conferencing and messaging, instant transcription into the written record, full-patient access to the record, translation into different languages, connectivity to multiple data sources, incorporation of multi-media educational materials. It-will also allow data from home-based diagnostic technology to be sent to clinicians. "Electronic communication will move medicine inexorably toward such transparency, enabling doctors and patients to share knowledge, responsibility, and decision-making more equally. We need to explore rapidly how this change will affect the quality of care for patients and the quality of life for doctors." The widespread dependence on Internet-based electronic communication to support a variety of commercial, educational, and entertainment needs and interests offers us an opportunity to develop innovative approaches to some long-standing problems-assuring the accessibility of clinicians to their patients and the effectiveness and timeliness of communication between them. It is exciting that we now have well-documented examples of how these new technologies can be used to enhance the quality of primary care practice in both large and small practice organizations.

Blue Cross Blue Shield Insurance Plans↗

PubMed2000

Recent trends in the financing of substance abuse treatment: implications for the future.

OBJECTIVE: This article focuses on the implications of a recent study of substance abuse (SA) and mental health treatment expenditures for substance abuse treatment policy. Public and private expenditures for SA treatment are estimated and compared with those for mental health and all health care in the period between 1987 and 1997. METHODS/DATA SOURCES: Estimates of SA treatment expenditures were segregated from the Health Care Financing Administration's National Health Accounts across the ten-year period. Information about use, charges, and payments by provider type, payer, and diagnosis was obtained from numerous nationally representative data sets and large claims databases. Those data were used to estimate SA treatment expenditures in the general service sector. For the specialty sector two specialty facility surveys were used to estimate SA treatment expenditures. Information from the two sectors was combined and reconciled to the National Health Accounts. PRINCIPAL FINDINGS. A dramatic shift in SA expenditures away from private financing and toward public payers, as well as a shift away from hospital treatment settings, occurred between 1987 and 1997. CONCLUSIONS: Evidence from this article and other research suggests that growth in SA expenditures has been contained relative to growth in all health spending. How savings from SA treatment are being invested and whether expenditure levels are appropriate to supply treatment of acceptable quality needs further study.

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