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PubMed1995

Facilitating continuity of care. The role of the patient care coordinator.

Continuity of care is essential for children with cardiac disease. The PCC works to ensure that these children continue to receive necessary care postdischarge. By collaborating with members of the health-care team, the PCC is able to coordinate appropriate services for patients in the Cardiovascular Program. The PCC acts as a resource for the interdisciplinary team by identifying postdischarge care options within the community. The PCC also furnishes information to community providers about individual patient care needs. Educating payers in regard to assessed postdischarge needs is another facet of the PCC role. In essence, the PCC provides a link among patients, families, interdisciplinary team members, community providers, and payers. This link facilitates continuity of care for patients in the Cardiovascular Program.

Cardiology↗

PubMed1994

Skewed incentives in our healthcare delivery system.

Policymakers agree that cost-containment in healthcare delivery cannot be attained unless the incentives for providers, patients, and payers can be changed. The authors review the existing incentives that have led to escalating costs and conflicting interests for providers, patients, employers, third-party payers and taxpayers. They examine the current incentives for each group and explore the changing incentives that the new integrated healthcare systems and managed care present. They conclude that the new systems are not a simplistic solution to the "healthcare crisis" in cost, access, and quality, but they emphasize that these new systems have already introduced new incentives for provider collaboration and cooperation. The traditional ties of the osteopathic medical profession allow a quick response to creating new integrated systems, but require collaboration to add tertiary care to the profession's strong primary care and community hospital base.

Conflict of Interest↗

PubMed1995

HIV care: a capitated alternative.

Given sufficient and participatory planning, a cluster of excellence for HIV/AIDS could be designed that could yield benefits to payers, providers, and patients. Such a cluster of excellence would be at risk for all care provided to an enrollment population made up of PWAs and would be globally capitated based upon the average cost of providing care to this population in the current, unmanaged health care environment. The cluster would be freed from conventional use constraints and be free to manage the care of their enrollment population with minimal payer interference. But it would be at risk for managing the cost of care to the enrollees within the global capitation rate.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Strategies for implementing global budgets.

Implementing global budgets requires setting a desired level of spending as well as establishing a set of policies to assure the budget will be met. Four alternative approaches are analyzed: one relies on all-payer rate setting coupled with volume controls; the second is a system of premium regulation that controls both the levels and rates of insurance premium increase; in another system, price competition among insuring organizations limits growth in spending while incorporating a global budget that limits the aggregate costs of all premiums; finally, either managed competition or premium regulation is combined with all-payer rate setting. The fourth model is singled out for its ability to control costs. An independent policy toward capital expenditures could increase the likelihood of success under any of the strategies.

Budgets↗

PubMed1994

The cost-effectiveness of prenatal carrier screening for cystic fibrosis.

OBJECTIVE: To evaluate the economic consequences of routinely offering cystic fibrosis-carrier screening to pregnant white women under 35 years of age. METHODS: Decision analysis was used to evaluate the health outcomes and medical costs of a screening program from the health care payer's perspective. Probabilities were taken from the literature; cost data were based on consultations with laboratory and hospital administrators. Sensitivity analysis was performed for key assumptions. RESULTS: If the test acceptance rate were 78% and the screening test identified 85% of carriers, a prenatal cystic fibrosis-carrier screening program would identify slightly more than half of the high-risk pregnancies in the population. For a cohort of one million pregnant women, it would cost $83 million. If the proportion of couples choosing abortion were 30% and the lifetime cost of medical care for cystic fibrosis were $243,650, the program would save $12 million in averted costs of medical care for cystic fibrosis, for a net cost of $71 million. Even after accounting for the savings in averted medical care for cystic fibrosis, the cost per high-risk pregnancy identified would be $82,000; the cost per unwanted cystic fibrosis birth averted would be $1.4 million. Results were sensitive to the cost and sensitivity of the screening test, but relatively insensitive to the test acceptance rate and therapeutic abortion rates between 50-100% among pregnancies identified with cystic fibrosis. CONCLUSION: A prenatal cystic fibrosis-carrier screening program would not save the health care payer money under most assumptions, but may be justified if the benefit of the early information provided to expectant parents is judged worth the cost.

Abortion, Induced↗

PubMed1993

Economic outcomes and contemporary pharmacy practice.

Health care reform will no doubt entail substantial reorganization of provider and payer systems to facilitate competition among groups or alliances of providers and payers. Pharmacists must be positioned to assume an active and significant role in the delivery of high-quality, affordable, and accessible care. To fill this role, pharmacists need to understand and use pharmacoeconomic evaluation--economic outcomes assessment for pharmaceutical products and services. To explore the value to society of pharmaceutical products and pharmacists, direct, indirect, and intangible costs must be studied. Pharmacoeconomic evaluation includes cost-benefit, cost-effectiveness, cost-minimization, and cost-utility analyses. As analytical tools, pharmacoeconomic studies can provide valuable information concerning the costs and consequences of pharmaceutical products and services. Pharmacists can play an important role in contributing to the economic efficiency of the health care system and in ensuring that economic, clinical, and humanistic dimensions are balanced in treatment decisions.

Economics, Pharmaceutical↗

PubMed1994

Cost-effectiveness of a routine varicella vaccination program for US children.

OBJECTIVE: To evaluate the economic consequences of a routine varicella vaccination program that targets healthy children. METHODS: Decision analysis was used to compare the costs, outcomes, and cost-effectiveness of a routine vaccination program with no intervention. Clinical outcomes were based on a mathematical model of vaccine efficacy that relied on published and unpublished data and on expert opinion. Medical utilization rates and costs were collected from multiple sources, including the Kaiser Permanente Medical Care Program and the California Hospital Discharge Database. RESULTS: A routine varicella vaccination program for healthy children would prevent 94% of all potential cases of chickenpox, provided the vaccination coverage rate is 97% at school entry. It would cost approximately $162 million annually if one dose of vaccine per child were recommended at a cost of $35 per dose. From the societal perspective, which includes work-loss costs as well as medical costs, the program would save more than $5 for every dollar invested in vaccination. However, from the health care payer's perspective (medical costs only), the program would cost approximately $2 per chickenpox case prevented, or $2500 per life-year saved. The medical cost of disease prevention was sensitive to the vaccination coverage rate and vaccine price but was relatively insensitive to assumptions about vaccine efficacy within plausible ranges. An additional program for catch-up vaccination of 12-year-olds would have high incremental costs if the vaccination coverage rate of children of preschool age were 97%, but would result in net savings at a coverage rate of 50%. CONCLUSIONS: A routine varicella vaccination program for healthy children would result in net savings from the societal perspective, which includes work-loss costs as well as medical costs. Compared with other prevention programs, it would also be relatively cost-effective from the health care payer's perspective.

Acyclovir↗

PubMed1993

Specialty service contracting.

Package pricing of specific services and procedures can be an effective cost-containment and marketing tool for payers and providers. Payers can secure fixed prices at discounted rates, and hospitals and physicians can retain and gain market share in an increasingly competitive health care market. Successful implementation of a package pricing strategy, however, requires a careful assessment of both market and operational factors. This chapter outlines how to identify opportunities for package pricing and how to establish rates and procedures.

Contract Services↗

PubMed1993

Reimbursement and pharmacoeconomic perspectives in biotechnology.

Problems associated with reimbursement for biotechnology agents and strategies for solving these problems are reviewed. Because of the many different insurers in the U.S. health care system, a variety of reimbursement strategies have been developed for the biotechnology drugs that are now reaching the market. These strategies can vary by insurer, contract, treatment setting, and patient condition. With the advent of high-cost biotechnology drugs, pharmacists have taken on the additional roles of institutional educators and reimbursement specialists. Case studies involving three biotechnology agents illustrate how insurers deal with reimbursement for these drugs. Thrombolytic agents are reimbursed under Medicare, but the diagnosis-related-group (DRG) payment for myocardial infarction was not changed until two years after alteplase was marketed. Septic shock therapies potentially face similar reimbursement problems, which are compounded because the drugs can be lifesaving--leading to longer hospital stays. When filgrastim is administered, the amount reimbursed depends on the treatment setting. When claims for biotechnology agents are denied, the institution or provider should contact the payer to provide the needed information (in the case of missing information) or to discuss payer policies that may need review. Through proper case management, pharmacists and other institutional personnel can ensure reimbursement for these lifesaving biotechnology therapies.

Biotechnology↗

PubMed1993

Professional satisfaction and dissatisfaction of family physicians.

BACKGROUND: Physicians' satisfaction with their professional life influences the quality of patient care they provide and helps to determine the number and type of students attracted to the various fields of medicine. In this study, we sought to delineate areas of satisfaction and dissatisfaction among family physicians. METHODS: A self-administered questionnaire was sent to all physicians in the state of Pennsylvania who were included in the 1990 directory of the American Board of Family Practice (N = 1944). RESULTS: Completed questionnaires were received from 1066 family physicians in full-time practice. Sixty-five percent were satisfied with their professional lives. Patient relationships, a sense of clinical competence, and their relationships with their partners were among the most satisfying aspects of practice for all family physicians. Problems identified included regulations by third-party payers and government agencies and the large amount of paperwork encountered in practice. There were significant (P < .001) differences in satisfaction between physicians in different practice arrangements. Significant differences between practice types were also found in the degree of dissatisfaction with third-party payers and government agencies, paperwork, isolation from other physicians, and the threat of a malpractice suit. CONCLUSIONS: Almost two thirds of family physicians are satisfied with their general professional lives. Conversely, one third are not. Clear areas of satisfaction and dissatisfaction have been defined for family physicians in general as well as for family physicians in various practice environments. This information may be useful in the development of policy to structure a medical system that meets the needs of both patients and physicians.

Adult↗

PubMed1993

How expenditure caps and expenditure targets really work.

Every organized payment system must contain its costs in order to keep within revenue without denying benefits. Fixed expenditure caps requiring the provider to operate within its annual financial grant can be imposed on organizations like hospitals, but are fiercely resisted by the medical profession. All financial arrangements with doctors are negotiated, including systems of fixed expenditure caps and more flexible expenditure targets. If the doctors accept the principle of caps and cooperate in achieving them, they do so only as part of a negotiated settlement to avoid a worse outcome. Government's power is minimized, even when government is the payer. Caps on the physicians' sector are unusual. Instead, we see the spread of flexible targeting systems, wherein cost overruns are compensated for by lower expenditure targets the following year. Medical associations in all countries resisted even these restraints for years, but eventually accepted them, provided that target setting, judgments of overruns, utilization control, and all other features are part of a joint negotiating system. Targeting systems are often complicated because they preserve the semiprivate character of statutory health insurance and they are the result of negotiated compromises. To succeed in controlling costs, they require the cooperation of the medical association and of the rank-and-file doctors--but they can succeed. The United States has enacted a small-scale targeting system for Medicare physician payments alone. It cannot become the method for universal health insurance, which must heed lessons from abroad. Only an all-payer system can cover an entire population and contain the costs of the system. A few government officials cannot dictate and implement expenditure goals, but a system of consultation is required for setting and carrying out targets. Impartial officials can regulate hospitals according to the guidelines produced by the consultations, but the record of the medical profession in the countries reviewed here is that they insist on negotiating the final rules and rates. Americans have become bewitched by the mirage of econometric formulas automatically governing a sector, but the real problem is to devise and operate a harmonious decision-making system.

Canada↗

PubMed1993

Factors affecting conversion rates to Medicaid among new admissions to nursing homes.

OBJECTIVE: This study examines conversion to Medicaid as a payment source among a cohort of newly admitted nursing home residents. DATA SOURCE: The longitudinal data used came from regular assessments of residents in the National Health Corporation's 43 for-profit nursing homes in Missouri, Kentucky, South Carolina, and Tennessee. This information system tracked all residents who were discharged, providing a comprehensive record that may have spanned multiple admissions. STUDY DESIGN: Using survival analysis methods, Cox regression, and survival trees, we contrasted the effect of state, initial payment source, education, age, and functional status on the rate of spend-down to Medicaid. DATA EXTRACTION METHODS: New-admission cohorts were created by linking an admission record for a newly admitted resident with all subsequent assessments and follow-up records to ascertain the precise dates of any payment source changes and other discharge transitions. PRINCIPAL FINDINGS: For the 1,849 individuals who were admitted as self-payers and who were still in the nursing home at the end of one year, there is a 19 percent probability of converting to Medicaid. All analytic methods revealed that education, age, and state of residence were predictive of spend-down among residents who were admitted as self-payers. CONCLUSIONS: Our results confirm the effect of education as an SES indicator and state as a proxy for Medicaid policy on spend-down. Future research should model the effects and duration of intervening hospitalizations and other transitions on Medicaid spend-down among new admissions.

Activities of Daily Living↗

PubMed1993

The high cost of hospital trauma care: an analysis of hospital length of stay, injury severity score, case mix index, and reimbursement-to-cost ratio.

We conducted a study to evaluate reimbursement characteristics for an urban hospital providing a high volume of trauma care. Complete clinical and financial data for 209 trauma patients admitted to the Bronx Municipal Hospital Center during September 1990 were entered into a trauma registry. Patients were categorized into three groups. Group 1 fulfilled criteria for reimbursement using the New York State Major Diagnostic Category 25 (NYSMDC 25) for trauma. Group 2 patients fulfilled New York City Emergency Medical Service 911 criteria for transport to a level 1 trauma center. Group 3 patients did not fit either category. Analysis included age, race, sex, length of stay, injury severity score, case mix index, payer source, and reimbursement-to-cost ratio. Of the patients studied, 77.5% were men. Hispanic, African-American, and white patients constituted 40.2%, 26.3%, and 17.2%, respectively, of the study population. The payer mix was 36.6% Medicaid; 20.8% self-pay; 19.1% no fault; 9.6% Blue Cross; 5.5% Medicare; 5% commercial; and 3.3% other. The study demonstrated that criteria for group 1 and group 2 define patients who constitute a distinct clinical group by injury severity score. As expected, the length of stay and case mix index were significantly higher for group 1, but they did not differ between group 2 and group 3. Group 1 was a small proportion (7.7%) of trauma patients admitted to the Bronx Municipal Hospital Center level 1 trauma center. Trauma admissions were treated at a net loss, with a projected high annual deficit of $5.3 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1996

The effects of ownership and ownership change on nursing home industry costs.

OBJECTIVE: This study examines the effects of ownership type and ownership change on nursing home cost structures, differentiating patient care costs from plant costs. DATA SOURCES: Administrative data from the Michigan Department of Social Services, Medical Services Administration (Medicaid), and the Michigan Department of Public Health are used. Cost data are based on audited cost reports for 393 nursing care facilities in Michigan in 1989. Other facility characteristics are based on data from the 1989 annual licensing and certification survey conducted by the Michigan Department of Public Health. STUDY DESIGN: A series of ordinary least squares regressions is estimated, in which the dependent variable is either per diem patient costs or per diem plant costs. Ownership types are defined as chain, proprietary non-chain, freestanding non-profit, government-owned, and hospital-based facilities. Pooled estimation techniques, as well as separate regressions by ownership type, are presented to test for interaction effects. Key variables include whether a facility changed ownership in the preceding five years and whether chain facilities are in-state- or out-of-state-owned, in addition to size, payer mix, and case mix. PRINCIPAL FINDINGS: Behavioral differences among nursing home ownership types in respect to patient care costs tended to distinguish government-owned and hospital-based facilities from the freestanding homes rather than the usual distinction between for-profit and not-for-profit classes. Variables traditionally included in nursing home cost studies, such as size, occupancy, payer mix and case mix, were found to have similar effects on per diem patient care costs for freestanding non-profit homes as well as for chain proprietary facilities. With regard to the effects of ownership change on per diem plant and per diem patient costs, however, there are few differences among ownership types. Chain and non-chain for-profit facilities, non-profit homes, and hospital long-term care units that had changed ownership reported significantly higher per diem plant costs than facilities without a change of ownership, but did not spend more on patient-related costs. Michigan Medicaid plant reimbursement system policy changes instituted in 1985 to promote continued ownership of facilities were not entirely successful. CONCLUSIONS: Non-profit homes look increasingly like their for-profit counterparts with respect to spending on patient care costs. Increased competition for the more lucrative private-pay patients, coupled with declining state Medicaid reimbursement to nursing homes, may have blurred the historical distinctions between the non-profit and for-profit sectors in the nursing home industry. An exception to increasing homogeneity within the nursing home industry is the tendency of proprietary homes to experience more frequent changes of ownership, which results in higher capital costs passed on to state Medicaid programs. Findings from this study indicate that while facility sales increase per diem plant costs, they do not result in increased spending for direct patient care, suggesting that state Medicaid programs may be indirectly subsidizing facility sales with no accompanying increase in expenditures for patient care. To discourage frequent facility sales, state Medicaid programs may need to consider alternative methods of reimbursing nursing home owners for capital costs.

Capital Expenditures↗

PubMed1997

Hemodynamic pacing--the outcomes perspective: a review of the literature.

Concerns about significant and rising health care costs have sent the health care pendulum swinging in a more conservative direction. A common-sense approach to health care suggested by outcomes advocates focuses on health care that will determine the best patient outcome for the best dollar value from the combined perspectives of patient, provider, and payer. For patients who require pacing, whether temporary or permanent, this review of the literature summarizes the perspectives of patient, provider, and payer favoring hemodynamic (atrial-based or dual-chamber) pacing.

Adult↗

PubMedDate not supplied

Managed care contracts. A guide for clinical case managers.

When healthcare executives speak of managed care, they often use the term generically to refer to any arrangement with a healthcare payer other than traditional fee-for-service reimbursement. All too often, the "management" aspect is missing from managed care, resulting in an arrangement that could more aptly be described as "discounted care." This lack of clinical representation is unfortunate, since there are numerous issues that have an impact on clinical care, including choice of referral providers, noncoverage of certain procedures or treatments, and similar issues that may influence the patient's plan of care. Organizations that approach managed care as a system that blends the resources of management, finance, and clinicians, will enjoy the greatest potential for success. With their practical experience and insight into the administrative and clinical issues that may be encountered, nurse case managers will ultimately be responsible for managing the care of the contracted population. As case managers are the vital link among payers, providers, patients, and families, it is essential that the case manager understand managed care concepts, be conversant in the terminology of managed care, function as a member of the team responsible for evaluating contracts, and periodically review existing arrangements. This article presents an overview of the managed care contract development process, and provides tools to enable the nurse case manager to participate in the contracting process.

Case Management↗

PubMed1996

The advanced practice nurse as case manager.

The dynamic interactions of the client, service provided, and payer are complex relationships in today's health care environment. An advanced practice nurse's abilities to care physically and psychosocially for clients and their families are essential within the case management framework. With a holistic view of clients' health status, the nurse case manager develops and carries out advanced practice functions that help achieve the best outcome for the client through effective interactions with clients, payers, and providers. Those functions, illustrated by the Star Case Management Model, include interpretation, advocacy, and surveillance.

Aged↗

PubMed1997

Medicaid, Medicare, and managed care. Case management for dually eligible clients.

A dually eligible person is one who qualifies for both Medicaid and Medicare benefits. When elderly persons need acute care services, they enter a different part of the service delivery system where Medicare is the major payer. Typically, this part of the system is disconnected from the long-term care portion. Rather than working together for the maximum benefit of consumers, each part of the system is motivated to guard its resources jealously. Integration of Medicare and Medicaid offers states the opportunity to demonstrate how better care can be provided by using resources more effectively. However, managed care may bring changes in care delivery and new payers for services which may affect the role of case managers.

Case Management↗