SEARCH · PubMed Health

Results for “Payers”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,207 records · Page 67Linked to original sources

PubMed1997

Overview: maintaining outcomes for total hip arthroplasty. The past, present, and future.

Developing and maintaining outcomes for total hip arthroplasty, resulting in meaningful and usable data, presents many challenges for today's clinician. Outcomes data collected must show patients' clinical, functional, and overall quality of life status. Data also must be appropriate to illustrate efficiency, effectiveness, and value of medical interventions provided to payers. Previous and current measures of assessing outcomes of total hip arthroplasty are presented, evaluated, and discussed. Recommended standards for the future, including the identification of specific data needed such as demographics, Short Form-36, patient satisfaction, length of stay, infection rate, return to surgery, and revision rates are introduced, leading to an outcomes based suggested standard of care for total hip arthroplasty with application to patients, providers, and payers.

Arthroplasty, Replacement, Hip↗

PubMed1997

An economic analysis of managed fee-for-service and direct reimbursement.

This economic analysis compares the direct reimbursement approach with the managed fee-for-service approach to the delivery and payment for dental care. Asymmetrical distribution of information between patients and dentists characterizes the market and gives rise to a principal-agent problem. To solve this problem, third-party payers have devised various methods for managing delivery and payment for dental care by monitoring and encouraging providers to assure a certain level of quality at defined costs. Direct reimbursement has been promoted by dental care providers as an alternative to the traditional third-party payer model and has at its core the elimination of many of the currently used managed care control mechanisms. The authors conclude that managed fee-for-service plan concepts deal with current economic issues more realistically than do direct reimbursement arrangements. Furthermore, the authors predict that direct reimbursement prevalence would lead to higher average prices for dental care and a change in the mix of services skewed toward high cost, marginally beneficial treatments.

Communication↗

PubMed1998

Fundamental mechanisms of managed behavioral health care.

Making sense of managed behavioral health care organizations (MBHOs) is difficult as they rapidly evolve in response to payer, member, legislative, and market demands. This article describes the basic mechanisms involved in managed behavioral health care's evolution, including the nature of carve-out organizations, carved-in services, the array of payment mechanisms between payer and MBHO, and between MBHO and mental health care providers. Additionally, types of delivery systems and mechanisms used to control utilization are outlined in the context of continuing health care change.

Health Care Sector↗

PubMed1998

Financial issues in defining levels for HIV/AIDS research.

This article outlines the issues in cost identification and fair payment for acquired immune deficiency syndrome (AIDS) research. Costs need to be better identified using activity-based costing methods to reveal the structural pattern of care. Patterns of care can be too expensive if they: (1) overutilize the hospital as the locus of care, or (2) underutilize prevention and education. Managers need to learn more about the cost identification issues payers face in designing a fair payment system. In the long run, more health care professionals would serve the cause of innovation and biomedical research if they all work together to define a stable fair funding mechanism. Payers need to learn that fair payment of indirect costs is not a bonus or a windfall profit.

Acquired Immunodeficiency Syndrome↗

PubMed1998

RBRVS (Medicare Resource-Based Relative Value Scale) revisited.

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 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.

Fees, Medical↗

PubMed1998

Reimbursement and documentation issues in an ambulatory ECT program.

In this era of decreased health resources and the strong influence of third-party payers, the financial advantages of ambulatory electroconvulsive therapy (ECT) should be well recognized by all concerned parties. However, to a large degree, third-party payers are only minimally aware of the availability and potential cost savings associated with this treatment modality. Also, documentation has been problematic, because reviewers unfamiliar with ECT have not been able to find the necessary data even when they are present in the chart. This article illustrates some of these problems and how they have affected our ambulatory ECT program.

Ambulatory Care↗

PubMed2005

How are volume-outcome associations related to models of health care funding and delivery? A comparison of the United States and Canada.

How models of health care financing and delivery affect patterns of procedure volumes, outcomes, and volume-outcome associations is not known. We compared volume-outcome studies done in Canada, which provides residents with universal, single-payer health care, with those done in the United States, to determine whether there was a difference in the likelihood of finding statistically significant volume-outcome associations. We analyzed 142 articles, most (90.1%) of which were from the United States. The articles described a total of 291 separate analyses. After adjusting for the clustering of multiple analyses in the same study, the likelihood of finding a statistically significant volume-outcome association was substantially lower in Canadian studies as compared with those from the United States (odds ratio 0.24, 95% confidence interval 0.08 to 0.74, p = 0.01). This result persisted after adjustment for the procedure/condition studied, and the number of study subjects. Canadian volume-outcome analyses are less likely to identify statistically significant volume-outcome associations than US studies, possibly because of the smaller size of some Canadian studies. It is also possible that different models of health care financing and delivery affect patterns of procedure volumes and volume-outcome associations. By promoting competition between hospitals and providers, market-based models may exacerbate existing variations in the quality of hospital care.

Canada↗

PubMed1996

Cost-effective provision of cardiac services in a fixed-dollar environment.

In the Canadian single-payer system, all hospital payments, including payments for cardiac operations, are negotiated with the government annually. Each hospital is required to remain within 50 cases of its negotiated surgical target. Physicians are paid on a capitated basis and are subject to penalties if negotiated targets are exceeded. There is a computerized waiting list for cardiac operation, with patients classified by an urgency rating scale and objectives set for the maximum period for any given urgency category. Experience has shown that many patients are delayed in the queue, waiting longer than expected for surgical procedures. Waiting times are not influenced by age, sex, or reoperative status, but are influenced by factors such as the presence of multiple risk factors, the number of diseased vessels, stability or unstability of angina, left main coronary artery disease, and recent angioplasty. Waiting time has not been shown to affect operative mortality, the incidence of postoperative low-output syndrome, or length of hospital stay. Canada's 30-year experience with the provision of cardiac services under managed care may provide useful information to hospitals and physicians in the United States currently confronting capitation. The following overview focuses on two critical issues: negotiation of costs and management of patient waiting lists.

Canada↗

PubMed2000

Importing budget systems from other countries: what can we learn from the German drug budget and the British GP fundholding?

The rising costs of pharmaceutical expenditures are a common problem for policy makers in most European countries. In two countries, budget systems for pharmaceutical spending exist(ed). In Great Britain, between 1991 and 1999 GP fundholders were responsible for prescribing costs, and in Germany an overall expenditure cap for pharmaceutical prescribing has been used since 1993. These two examples are analysed in order to identify the conditions that are needed for successfully implementing budget systems for prescribing costs in other countries. It is argued, that a good budget system balances the provision of enough information for budget holders to monitor their expenditures on the one hand, against an explosive increase of transaction costs on the other hand. Apart from that, it makes doctors responsible only for expenditures that they themselves can actually control, and does not provide them with an incentive to use that discretionary power by shifting expenditures to other health care sectors. A good information infrastructure is needed for the implementation of budget systems in general. For the introduction of fundholding, a number of additional criteria need to be met, such as having gate-keeping GPs with personal lists and having a single-payer system.

Budgets↗

PubMed2006

True versus reported waiting times for valvular aortic stenosis surgery.

OBJECTIVES: To produce a universally accepted waiting time definition for cardiovascular surgery, present the rationale for this definition, and compare data on current waiting times in British Columbia based on this definition versus the current definition in patients waiting for aortic stenosis surgery. STUDY DESIGN: The present study is a retrospective data analysis. SETTING: The fixed-dollar, single-payer health care delivery system in British Columbia. PATIENTS: All residents of British Columbia who were at least 22 years of age and who were placed on a waiting list for aortic valve surgery with the diagnosis of aortic stenosis between January 1, 1991, and December 31, 2000, were eligible for the present study. INTERVENTIONS: Dates of physician visits, procedures and surgery were obtained from the British Columbia Cardiac Registries and Medical Services Plan databases. True waiting times from physician visits to procedures and surgery were calculated. RESULTS: Of the 2516 patients booked for aortic valve surgery with a primary diagnosis of aortic stenosis, 2237 subjects (88.9%) were eligible for analysis after exclusions. The eligible patients ranged in age from 22 to 95 years, and 36.8% were female. The true median waiting time was 243 days (148 days [25th percentile], 397 days [75th percentile]), which was 3.2 times the interval currently reported as the waiting time (75 days [42, 127]). Thirty-nine patients died while waiting for surgery. Patients used more resources while waiting for surgery than after surgery. CONCLUSIONS: True waiting times for surgery for aortic stenosis in British Columbia are significantly longer than reported waiting times. The authors propose that the wait list time for cardiovascular surgery be redefined as "the time interval between the patient's first contact with a medical care provider with symptoms or signs which ultimately lead to cardiovascular surgery and the date of that surgery".

Adult↗

PubMed1996

Reminding and monitoring: new uses of administrative data for preventive care.

This article illustrates how administrative data can be used to improve population health in an environment of fiscal constraint. In our universal single-payer health system, health care providers submit standardized data. This allows provinces to create health information utilities that generate population-based data that can be used for research and health care delivery. Although more study is needed to determine the cost-effectiveness of using such data to raise the rates of primary and secondary prevention, it appears that appropriately designed information systems could improve population health with relatively little additional cost.

Aged↗

PubMed1997

Universal health care coverage in the United States: barriers, prospects, and implications.

Universal health care coverage has long been a concern for social workers. This article examines barriers to and prospects for universal coverage in the United States. The article identifies major obstacles to universal coverage, addresses current problems with the U.S. health care system, discusses the debate over Medicare and Medicaid, and considers possible routes to universal coverage. The article also discusses implications for NASW and other supporters of a single-payer system.

Health Care Reform↗

PubMed2003

A province-wide study of the association between hospital resource allocation and length of stay.

The relationship between hospital resource allocation and clinical efficiency is poorly understood. Within the single-payer healthcare system in Ontario, Canada, the association between hospital spending patterns and length of stay was studied using data from 1117090 patient discharges in 1997/8 at 162 of 171 acute care hospitals. A weighted regression model was created using an overall hospital length of stay index (actual length of stay divided by predicted length of stay) as the dependent variable. Control variables included: hospital size, teaching activity, occupancy rate, rural location and geographic region. Four independent spending variables were defined as a percentage of total hospital spending: nursing, ambulatory care, administration and support, and diagnostics and therapeutics. The reduced regression model had an r-squared of 0.45. Across all spending variables, hospitals spending relatively too little or too much had significantly longer length of stay. Hospitals' overall pattern of resource allocation was also significantly associated with length of stay. Thus, measurable clinical effects can be seen with resource allocation decisions made by hospital management, supporting the need for rigorous decision-making processes. Future research should focus on exploring the nature of this relationship and the potential interdependencies among hospital services that cause this effect.

Acute Disease↗

PubMed2000

An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii.

OBJECTIVES: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii. METHODS: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses. RESULTS: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women. CONCLUSIONS: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

Adult↗

PubMed2003

National health insurance or incremental reform: aim high, or at our feet?

Single-payer national health insurance could cover the uninsured and upgrade coverage for most Americans without increasing costs; savings on insurance overhead and other bureaucracy would fully offset the costs of improved care. In contrast, proposed incremental reforms are projected to cover a fraction of the uninsured, at great cost. Moreover, even these projections are suspect; reforms of the past quarter century have not stemmed the erosion of coverage. Despite incrementalists' claims of pragmatism, they have proven unable to shepherd meaningful reform through the political system. While national health insurance is often dismissed as ultra left by the policy community, it is dead center in public opinion. Polls have consistently shown that at least 40%, and perhaps 60%, of Americans favor such reform.

Community Participation↗

PubMed2003

Universal coverage and public health: new state studies.

Recent evaluations of the California Health Service Plan (CHSP) confirmed that financing health care through a single government payer can provide universal coverage-while saving significantly on health care spending-to a degree unparalleled by alternative approaches. Public ownership of the delivery system can further provide authority and accountability for critical reforms that improve the population's health and quality of care, including coordination of the delivery system. The federal government's State Planning Grant Program provides states with funding to develop plans to cover their uninsured populations. California created a Health Care Options Project that requested proposals that could expand coverage and contracted with a financial modeler and a qualitative analyst to evaluate the resulting plans. The CHSP was one of 9 plans evaluated through this process.

California↗

PubMed2003

Health care reform: lessons from Canada.

Although Canadian health care seems to be perennially in crisis, access, quality, and satisfaction in Canada are relatively high, and spending is relatively well controlled. The Canadian model is built on a recognition of the limits of markets in distributing medically necessary care. Current issues in financing and delivering health care in Canada deserve attention. Key dilemmas include intergovernmental disputes between the federal and provincial levels of government and determining how to organize care, what to pay for (comprehensiveness), and what incentive structures to put in place for payment. Lessons for the United States include the importance of universal coverage, the advantages of a single payer, and the fact that systems can be organized on a subnational basis.

Canada↗

PubMed2003

A review of data on the U.S. health sector. June 2003.

This report presents information on the state of the U.S. health sector in early 2003. It provides data on the insured and uninsured and their access to health care; the increasing costs of care; the role of corporations--including the hospital, pharmaceutical, and insurance industries--and corporate money in health care; and Medicare HMOs. The author provides updates on health care policy and proposals at the state (including single-payer bills) and federal levels; the Bush proposals on Medicare and Medicaid; and the health care reform proposals put forward by the Democratic presidential candidates.

Drug Industry↗