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At least 1,171 records · Page 65Linked to original sources
PubMed2005

Healthcare spending among community-dwelling adults with schizophrenia.

BACKGROUND: Although expenditures for schizophrenia have been documented previously, direct medical expenses have not been updated to reflect the most recent national data available. OBJECTIVE: To identify current direct medical expenditures for schizophrenia and comorbidities among community-dwelling adults in the United States. STUDY DESIGN: Cross-sectional. METHODS: Nationally representative data from the 2001 and 2002 Medical Expenditure Panel Surveys were analyzed to identify community-dwelling adults, aged 20 years, who incurred expenses for selected comorbidities. Annual direct medical spending estimates by site of service and payer source were produced using the average of these 2-year data. Mean and median per-person comorbidity costs among patients with schizophrenia expenses were determined for the following conditions: diabetes, hypertension, heart disease, and dyslipidemia. RESULTS: Five hundred seventy-one thousand community-dwelling adults incurred USD 2.13 billion per year in direct medical expenses for schizophrenia in 2001-2002; mean and median yearly per-patient expenses were USD 3726 and USD 1748, respectively. Inpatient care accounted for 13% of expenditures, while ambulatory care and prescription drugs accounted for 75%. Medicaid incurred USD 1 billion spent on schizophrenia treatment. Mean per-person spending for schizophrenia patients with comorbidities ranged from USD 3913 per year for those with comorbid hypertension to USD 5618 per year for those with comorbid dyslipidemia. Mean annual total healthcare expenditures for patients with schizophrenia ranged from USD 5990 for those with no comorbid conditions to USD 12 292 for those with comorbid hypertension. CONCLUSION: The majority of schizophrenia expenses incurred by patients living in the community occur in an outpatient setting and not in the hospital. Medicaid is the primary payer source for this condition. Among adults with schizophrenia, the costs of comorbidities vary by condition, but are associated with increased expenditures.

Adult↗
PubMedDate not supplied

Opportunities for administrators to promote disease management.

Studies of disease management (DM) have shown that patients who participate in such programs achieve better health status and make fewer emergency room visits. Private and government payers have recently increased their efforts to promote DM initiatives through financial incentives to healthcare providers. This article explores opportunities for administrators of health services organizations (HSO) to promote DM in the current political and economic environment. Our survey of professionals (DM leaders, physicians, and DM nurses) in six DM programs reveals these professionals' assessments of the key players and resources that they deem important to their respective DM programs. They view DM programs as heavily dependent on the support of physicians, nurses, and health plan leaders but relatively less so on the support of HSO administrators- a situation that may suggest opportunities for administrators to take on greater leadership in moving the HSO toward developing DM programs. Survey results also indicate a strong need for the integration of resources such as communication systems, electronic medical records, and DM reporting. Taken collectively, these needs suggest a number of strategies for the administrator to play a larger role in supporting the adoption and effective implementation of DM. In the article, we propose that DM programs can benefit substantially from an administrator who can demonstrate a thorough knowledge of DM-related government and private-payer initiatives and who has the ability to provide leadership to develop and implement viable DM programs. Valued contributions that the administrator should bring to the table include support of standardized DM processes, use of practice guidelines, and provision of pertinent information systems.

Administrative Personnel↗
PubMed2005

No small change: payment trends call for big preparations for 2006.

Payment trends that hospitals will need to respond to in 2006 are related to five areas of concern: The need to audit commercial insurers' payment for accuracy. The need for contract modeling and data-driven organization. The shift of volume risk from payers to hospitals. The shift of cost risk from payers to hospitals. The rise of consumer-directed health plans and related pay-for-performance and tiered pricing initiatives.

Financial Management, Hospital↗
PubMed2006

Unbundling the confusion about "unbundling" of charges.

Rejecting service codes on the basis that they have been unbundled has become a popular way for payers to reduce total billed charges. However, the contract between the hospital and the payer, and not Medicare or some hastily manufactured and inconsistent industry standard, controls the obligation to pay for healthcare services.

Economics, Hospital↗
PubMedDate not supplied

Utilization of a hospital for treatment of pediatric dental emergencies.

PURPOSE: The purpose of this study was to investigate dental emergencies treated at a hospital clinic and emergency department (ED) to: (1) analyze emergency types; (2) determine reasons for seeking hospital care; and (3) examine trends compared to previous studies from this institution. METHODS: Records of 2,683 emergencies from 1995 to 2003 were reviewed. Demographics, reason for seeking care, and treatment details were analyzed overall by emergency type and for subgroups of patients with severe early childhood caries (S-ECC) and patients referred from other EDs. RESULTS: Emergencies were: 51% trauma, 40% caries, and 9% "other" emergencies unrelated to trauma or caries. Common patient characteristics were: (1) young age; (2) non-Caucasian ethnicity; (3) Medicaid as payer; (4) no dentist; and (5) proximity to the hospital. Caries emergencies increased significantly over the study period (P = .008), and 22% had S-ECC. Patients referred from other EDs were: 11% of trauma patients who commonly required sutures and/or extractions; and 3% of caries patients, 82% with extraoral swelling. CONCLUSIONS: Characteristics of patients seeking hospital care for dental emergencies were: (1) young age; (2) non-Caucasian ethnicity; (3) Medicaid as payer; (4) no dentist; and (5) proximity to CHRMC. Use differed by ethnic groups: Caucasians presented mostly for trauma; African Americans presented equally for caries and trauma; and Hispanics and Asians presented primarily for caries. Access to care, caries, and severe early childhood caries remain significant problems despite multiple programs targeting children's' oral health in Washington State.

Adolescent↗
PubMed2006

The volume-outcome debate revisited.

Multiple studies support the intuitive association between higher provider procedure volume and better clinical outcomes. Health care purchasers and payers have been seeking ways to direct patients to high-volume providers to improve the quality of care received and to avoid costs associated with higher surgical morbidity. Volume-based referral has faced resistance from providers who are concerned that the use of volume instead of more direct measures of surgical quality will result in unfair discrimination. On close examination, volume-based referral policies also appear to be more congruent with payers' interests than the interests of individual patients and providers. Furthermore, a policy of volume-based referral does not address surgical quality directly, is applicable to only a very small segment of surgical care, and is logistically problematic. However, in the absence of viable alternative measures of surgical quality, imperfect proxies such as volume will likely continue to be a significant part of the national dialogue surrounding surgical quality.

Delivery of Health Care↗
PubMedDate not supplied

High standards. A decade after the law went into effect, there is still debate about the pros and cons of the HIPAA privacy and electronic transaction regulations.

When congress passed the Health Insurance Portability and Accountability act in 1996, the goal was to create a simpler, more standardized system that would eventually lower health care costs; reduce errors through safe, universally accepted electronic communication of health care transactions; and eliminate paper claims. Ten years later, the jury is still out on whether HIPAA has been worth the time, energy, and financial investment for insurers. That's not to say, however, that HIPAA hasn't generated benefits while also creating new challenges. "Standards made sense," says Tom Fitzpatrick, Horizon Blue Cross Blue Shield of New Jersey's director of enterprise strategic planning, "but no one ever said it would be fast, cheap, or easy. It was challenging to integrate proprietary claims systems and legacy software with the new standards that took effect in October 2003. But that wasn't the end of the story. HIPAA's privacy and security rules and the standard identifiers have meant even more upgrades and improvements and have required payers to spend millions of additional dollars over the past three years on HIPAA compliance." According to a set of quarterly surveys conducted by HIMSS/Phoenix Health Systems, progress has actually been fairly rapid. On the other hand, some things have remained much the same. In 2003, payers cited "understanding/interpreting the legal requirements" as the most difficult aspect of the HIPAA remediation process, followed by "achieving successful integration of new policies and procedures" and "resolving issues with third parties". In 2006, the barriers are similar, with users citing the same top two struggles.

Confidentiality↗
PubMed1991

The Maryland experience and a practical proposal to expand existing models in ambulatory primary care.

Two unique models for caring for the uninsured and underinsured are operating in Maryland. The first is a group practice, primary care model with a unique ambulatory Medicare waiver that has had a positive impact on patients and physicians. The second is a financial model--an all-payer prospective rate-setting system for all critical care inpatient hospitals that, during a 13-year period from 1977 through 1989, has saved the citizens of the state approximately $5.361 billion, has allowed hospitals to provide $1.657 billion of charity care and bad debts, and has earned $517 million in net profits. The reasons for the success of each of the models are discussed and form the basis for a practical and politically feasible proposal: merge the best aspects of each model into an ambulatory primary care-based model financed through an all-payer prospective charge system.

Ambulatory Care↗
PubMed1990

Pharmacoeconomics: therapeutic and economic considerations in treating the critically ill patient.

The critically ill patient is at high risk for developing complications and, consequently, higher costs of treatment. Because of the high costs associated with these patients, healthcare payers are demanding the development of criteria to ensure cost-effective care. Pharmacists can play an important role in ensuring cost-effective and appropriate care of critically ill patients. The length of hospital stay, the single most important variable influencing the overall cost of patient care, is increased by lack of a structured patient management plan and by the development of complications. Many of these complications are preventable by appropriate drug therapy and monitoring, thus representing the cost factor most controllable by pharmacists. Pharmacists can use newer tools such as cost-effective analysis and clinical decision analysis to identify and utilize drug therapies that result in decreased complications and decreased length of hospital stay, as measured by decreased costs. Equally important is the development of criteria for the appropriate use of drug therapies. Pharmacists must take an active role in working with physicians, nurses, payers, and risk managers.

Cost-Benefit Analysis↗
PubMed1989

The impacts on hospital costs between 1980 and 1984 of hospital rate regulation, competition, and changes in health insurance coverage.

In this paper, we report the results of an analysis of hospital expenses in 43 large SMSAs between 1980 and 1984. We found that hospital rate regulation--specifically Medicare's TEFRA and PPS and state multi-payer systems--was the single most important factor leading to the slowdown in the rate of increase in hospital costs between 1980 and 1984. In 1984, hospital costs covered by Medicare's PPS were 12.5% lower than they would have been in the absence of rate regulation, and in the four states covered by all-payer rate regulation, hospital costs were between 11% and 15% lower. In contrast, changes in the proportion of people either covered by employer-group health insurance or enrolled in HMOs, reduced hospital costs by less than 1%. Measures of competition suggest that hospital costs are higher where there is more competition. We also found that almost all of the effect of regulation on costs came from gains in the efficiency of producing hospital care and/or from reductions in the quality of care. It appears that controlling hospital payment rates gave hospitals a strong incentive to provide care at lower cost.

Catchment Area, Health↗
PubMed1988

The impact of alternative hospital payment systems on Medicaid costs.

From 1982 onward, 25 states adopted three broad strategies to control their Medicaid hospital costs: multiple-payer rate setting, Medicaid-only prospective payment, and selective contracting. In this analysis of the three approaches, I found that the multiple-payer systems were particularly effective at controlling Medicaid payments because of their ability to control statewide hospital costs. The Medicaid-only prospective payment systems were also successful, but appear to be effective only in the short term. California's Medicaid-only selective contracting program was also successful, largely because of the simultaneous implementation of cost-control incentives for all hospitals in the state. I also found sharp reductions in Medicaid admissions where rates were set low relative to costs, as well as a shift in Medicaid admissions to public hospitals in Medicaid-only prospective payment states.

California↗
PubMed1986

Financing home health-care products and services.

Factors affecting growth of the home health-care (HHC) industry are identified, basic principles of HHC product and service reimbursement are reviewed, and third-party payer coverage criteria and payment methods for HHC products and services are discussed. Reimbursement for HHC services has suffered from the absence of a financing mechanism for long-term care. Providers of HHC services are burdened by the laborious process of obtaining favorable coverage determinations for short-term-care patients when home care substitutes for institutional care. When home care is covered benefit, there is often a complex mix of confusing coverage rules, coverage criteria that differ among public and private payers, and interpretations of coverage criteria that differ among local carrier personnel. Private financing obstacles and federal budget deficits will deter the development of an adequate financing mechanism for HHC. The growth of health-maintenance organizations and competitive medical plans will help to reduce reimbursement complexity. Long-term changes in HHC financing may become less important if capitation payment is successful.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1988

Competition, regulation, and hospital costs, 1982 to 1986.

We used data on 5490 nonfederal, short-term general hospitals to evaluate the relative effectiveness of regulatory and market-oriented cost-control policies on hospital cost inflation between 1982 and 1986. All-payer rate-regulation programs reduced inflation rates by 16.3% in Massachusetts, 15.4% in Maryland, and 6.3% in New York, compared with the control hospitals in 43 states with neither all-payer rate regulation nor an aggressive market-oriented strategy. New Jersey hospitals experienced a rate of cost inflation similar to the control hospitals. Given the effectiveness of its regulatory program in the 1970s, however, New Jersey began and ended the period from 1982 to 1986 with the lowest costs, controlling for wages and patient mix. California's market-oriented cost-control policy reduced inflation rates by 10.1%. Hospitals with large percentages of patients insured by Medicare's prospective payment system experienced cost inflation rates 16.1% lower than hospitals with small percentages of Medicare patients. Investor-owned hospitals experienced rates of cost increase 11.6% higher than private nonprofit hospitals and 15.0% higher than public hospitals.

Cost Control↗
PubMed1987

Regulatory and legal aspects of outpatient surgery.

This is a brief summary of the regulatory and other legal issues that may be raised by the provision of surgery outside of the hospital environment. Despite these potential problems, however, outpatient surgery embodies significant potential for hospitals, physicians, patients, and third-party payers. Outpatient surgical facilities embody the potential to achieve two of the government's primary goals: the provision of high-quality services and the reduction of health care costs. Third-party payers, similarly, are increasingly recognizing the benefits of outpatient surgery. Some are providing "facility" payments to cover the overhead costs of such facilities, or at least, providing an add-on to physicians' professional fees, for example, UCR (usual and customary rates) plus 20 per cent, if surgery is conducted in an office setting. Health maintenance organizations and other alternative delivery systems are actively seeking to enter into contracts with ambulatory surgical centers to provide outpatient surgical services to their enrollees because HMOs and other alternative delivery systems maximize profits by decreasing inpatient hospital utilization. In the years ahead, certificate of need and other regulatory barriers to the establishment of ambulatory surgical centers may fall as states increasingly begin to reassess the costs and benefits of certificate of need programs. In short, the trend toward outpatient surgical facilities and outpatient care generally is one that is here to stay.

Ambulatory Surgical Procedures↗
PubMed1984

An analysis of hospital case mix, cost, and payment differences for Medicare, Medicaid, and Blue Cross Plan patients using DRGs.

To increase our understanding of case mix as a major contributor to variability in hospital costs, we examined the relationship among case mix, resource consumption, and payments for all Medicare, Medicaid, and Blue Cross Plan patients discharged from 28 hospitals in New York State. Case mix differences among the three payers were found to contribute to differences in overall average cost per case, although residual differences in costs existed at the DRG level. Medicare and Medicaid payments more often covered the actual costs of their patients than did Blue Cross Plan payments. Our results indicate the importance of payer-specific data in the design of effective and equitable reimbursement and cost containment strategies.

Blue Cross Blue Shield Insurance Plans↗
PubMed1978

Profitability analysis in the hospital industry.

Measures of marginal profit are derived for the two payment classes--cost payers and charge payers--that the hospital industry must consider in profitability analysis, i.e., prediction of the excess of revenue over expenses. Two indexes of profitability, use when payment mix is constant and when it is nonconstant, respectively, are derived from the two marginal profit measures, and one of them is shown to be a modification of the contribution margin, the conventional measure of profitability used in general industry. All three measures--the contribution margin and the two new indexes of profitability--are used to estimate changes in net income resulting from changes in patient volume with and without accompanying changes in payment mix. The conventional measure yields large overestimates of expected excess revenue.

Costs and Cost Analysis↗
PubMed1995

Legal liability under managed care.

Market forces are driving the delivery of health care into managed care. New alignments among health care providers, payers, utilization reviewers and hospitals create new legal liability. Better-informed patients, concurrent credentialing by hospitals and payers, and new incentives to reduce hospital and physician-related costs have resulted in new federal legislation and agencies that reshape health care delivery and legal liability.

Hawaii↗