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PubMed2001

Medicare program; changes to the hospital outpatient prospective payment system for calendar year 2002. Final rule.

This final rule revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements, including relevant provisions of the Medicare, Medicaid,and SCHIP Benefits Improvement and Protection Act of 2000, and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. This final rule also announces a uniform reduction of 68.9 percent to be applied to each of the transitional pass-through payments.These changes are applicable to services furnished on or after January 1, 2002.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

The costs of epilepsy in Italy: a prospective cost-of-illness study in referral patients with disease of different severity.

PURPOSE: [corrected] Epilepsy poses a considerable economic burden on society. However, information is insufficient on the comparative costs of different disease varieties. The purpose of this study was to compare the direct costs of epilepsy in referral patients with disease of different severity and duration. METHODS: Patients with newly diagnosed epilepsy (NDE), seizure remission (SR), occasional seizures (OS), frequent non-drug-resistant (NDR) and drug-resistant (DR) seizures, and surgical candidates (SC) from 14 epilepsy centers were the target population. All patients were followed prospectively for 12 months and all medical and paramedical contacts for diagnostic and therapeutic services were noted with details, using ad-hoc diaries and semistructured questionnaires. RESULTS: The study population comprised 525 consecutive children and adults with partial (68%), generalized (25%) and undetermined epilepsy (4%) as follows: NDE 70; SR 131; OS 108; NDR 101; DR 107; SC 8. Ambulatory visits (mean 2.8 per patient per year) were the leading service in all groups, followed by EEG recordings (1.8) and biochemical assays (1.1). At entry, the commonest drugs were carbamazepine (50%), valproate (37%), phenobarbital (21%), vigabatrin (14%) and lamotrigine (11%). New antiepileptic drugs (AED) were used increasingly with the severity of the disease. The total annual costs varied significantly across groups: 3945 Euro (SC), 2198 Euro (DR), 1626 Euro (NDR), 1002 Euro (NDE), 558 Euro (OS), 412 Euro (SR). The main item of expenditure was hospital stay (including day-hospital), followed by drug treatment and outpatient visits. The costs of outpatient services, hospital services and drugs varied significantly across groups. CONCLUSIONS: The direct costs of epilepsy vary significantly depending on the severity of the disease and the response to treatment. Hospital admissions and drugs are the commonest items of expenditure.

Adolescent↗
PubMed1992

Mild bleeding disorders. A clinical and laboratory study.

OBJECTIVE: To investigate in-vitro haemostasis in subjects with symptoms suggesting a mild bleeding disorder. DESIGN: A prospective study in which an extensive range of in-vitro tests were applied unselectively. SETTING: Patients were referred from community-based practices and hospital outpatient services. PATIENTS: Ninety-three consecutive patients were examined. Hospital patients with severe illness were excluded. CLINICAL FEATURES: Patients presented with easy bruising (68%), epistaxis (12%), excessive operative bleeding (7%), menorrhagia (4%), haematuria (3%), dental bleeding (1%) and bleeding from other sites (5%). In no instance was the bleeding life threatening. OUTCOME MEASURES: Results of laboratory tests for patients presenting with the symptoms of a mild bleeding disorder were compared with the results for a healthy reference group. RESULTS: Abnormal results of in-vitro tests were found in 53% of the subjects. Thirteen per cent had a prolonged bleeding time, of whom the majority had abnormal results of other in-vitro tests. Von Willebrand's disease was diagnosed in 7% of patients, although only half of these had a prolonged bleeding time. CONCLUSIONS: Abnormal results of in-vitro tests were prevalent among subjects with symptoms of mild bleeding disorder. Easy bruising was as powerful a clue as any other bleeding manifestation to the presence of an abnormal in-vitro test result.

Bleeding Time↗
PubMed2005

Medicare program; application of inherent reasonableness payment policy to Medicare Part B services (other than physician services). Final rule.

This final rule finalizes the process that was set forth in an interim final rule published on December 13, 2002, for establishing a realistic and equitable payment amount for Medicare Part B services (other than physicians' services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or grossly deficient. This process does not apply to services paid under a prospective payment system, such as outpatient hospital services or home health services. The December 2002 interim final rule also described the factors we (or our carriers) will consider and the procedures we will follow in establishing realistic and equitable payment amounts for Medicare Part B services. In addition, this final rule responds to public comments we received on two provisions in the December 13, 2002 interim final rule relating to how we define grossly excessive or deficient payment amounts and to the criteria for using valid and reliable data in applying the inherent reasonableness authority.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Costs, resource utilisation and financing of public and private hospitals in Uganda.

A descriptive cross-sectional, retrospective cost analysis was conducted in a public and private hospitals in Arua district, Uganda with the aim of assessing the resource use, costs, and financing of those hospitals. It employed the "full costing" approach to hospital costing. The results showed that most of the government recurrent expenditure on health facilities in the district went to the public hospital, while most of the revenues at the private hospital was from donations. The distribution of costs by category of inputs showed that materials and supplies costs were highest in both hospital, followed by employee costs. The administration, pharmacy and store had the highest cost at both hospitals. The cost of the kitchen was very high in the public hospital. The ratio of the unit costs of an out patient visit to an inpatient day and to the unit cost per case treated was 1:1:6 in the private and 1:7:46 in the public. This indicates the relative low cost of public hospital outpatient service and the relative high cost of the outpatient in the private hospital. The employee costs and the drug costs were the most important components of the unit costs in the OPD at both hospitals while in the inpatient wards, besides the above mentioned components, there were also the kitchen, blood bank (public) and theatre in both hospitals. It is concluded that hospitals should look for ways of increasing the level of recurrent funding available to them by increasing the efficiency of their operations and by mobilising additional resources from other sources other than government.

Costs and Cost Analysis↗
PubMed2005

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2006 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. In addition, the final rule with comment period describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. This final rule with comment period also changes the requirement for physician oversight of mid-level practitioners in critical access hospitals (CAHs). In this final rule with comment period, we also are responding to public comments received on the November 15, 2004, final rule with comment period pertaining to the ambulatory payment classification (APC) group assignment of Healthcare Common Procedure Coding System (HCPCS) codes identified in Addendum B of that rule with the new interim (NI) comment indicator. These changes are applicable to services furnished on or after January 1, 2006.

Ambulatory Care↗
PubMed1998

Differences between metropolitan and country public hospital allied health services.

This paper compares patient and episode characteristics in allied health services delivered in country and metropolitan hospitals. Eight public hospitals (46 allied health services) participated in the study (three country and five metropolitan sites, situated in South Australia, Queensland and Tasmania). Standardised rates of patient throughput were similar for country and metropolitan allied health services, despite smaller numbers of country staff providing services to larger geographical areas. Although the differences were not significant, country patients were generally older and had more chronic conditions than metropolitan patients. Fewer country patients than metropolitan patients were eligible for rebates in the private sector. In addition, fewer alternative services were available in country communities, which heightened the role of the public hospital outpatients services within the community. This paper provides an argument for similar funding arrangements for country and metropolitan ambulatory allied health services.

Adolescent↗
PubMed1995

Service mix in the hospital outpatient department: implications for Medicare payment reform.

OBJECTIVE: To determine if implementation of a PPS for Medicare hospital outpatient department (HOPD) services will have distributional consequences across hospital types and regions, this analysis assesses variation in service mix and the provision of high-technology services in the HOPD. DATA: HCFA's 1990 claims file for a 5 percent random sample of Medicare beneficiaries using the HOPD was merged, by hospital provider number, with various HCFA hospital characteristic files. STUDY DESIGN: Hospital characteristics examined are urban/rural location, teaching status, disproportionate-share status, and bed size. Two analyses of HOPD services are presented: mix of services provided and the provision of high-technology services. The mix of services is measured by the percentage of services in each of 14 type-of-service categories (e.g., medical visits, advanced imaging services, diagnostic testing services). Technology provision is measured by the percentage of hospitals providing selected high-technology services. FINDINGS/CONCLUSIONS: The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS. HOPDs in major teaching hospitals and hospitals serving a disproportionate share of the poor play an important role in providing routine visits. HOPDs in both major and minor teaching hospitals are important providers of high-technology services. Other findings have implications for the structure of an HOPD PPS as well. First, over half of the services provided in the HOPD are laboratory tests and HOPDs may have limited control over these services since they are often for patients referred from local physician offices. Second, service mix and technology provision vary markedly among regions, suggesting the need for a transition to prospective payment. Third, the organization of service supply in a region may affect service provision in the HOPD suggesting that an HOPD PPS needs to be coordinated with payment policies in competing sites of care (e.g., ambulatory surgical centers).

Aged↗
PubMed2000

Mental health care in Italy: organisational structure, routine clinical activity and costs of a community psychiatric service in Lombardy region.

The Magenta Community Mental Health Centre (CMHC) is the public agency responsible for providing adult psychiatric care to about 85,000 adult residents. In 1995, it had 1,145 clients and incurred costs of Euro 1.9 millions. Average cost per patient and per adult resident were Euro 1,661 and Euro 22.2, respectively. These values mask large variation across diagnosis: while patients with schizophrenia and related disorders had an average cost of Euro 3,771, those with neurotic and related disorders had an average cost of Euro 439. Patients with schizophrenia and related disorders (28% of the patients) absorbed about 60% of total costs and made extensive use of several types of services (hospital, outpatient, domiciliary, social and rehabilitative care). Since integrating different types of services is the key element of Italian psychiatric care, the new fee-for-service system adopted by the NHS to fund providers does not appear appropriate, particularly for schizophrenic patients.

Adolescent↗
PubMedDate not supplied

A new payment system for outpatient services? The implications for radiology.

Congress is now contemplating the most significant change in outpatient payment methodology in Medicare's 31-year history. It may approve a proposal by the Health Care Financing Administration (HCFA) to establish a Medicare prospective payment system for hospital outpatient departments. In March 1955, five years after a Congressional directive to develop a new outpatient payment system, HCFA delivered its proposal recommending use of the ambulatory patient groups (APG) classification system for determining payment of hospital outpatient services. The APG system, which uses outpatient procedures as its primary variable, divides all such procedures into one of three categories: 1) significant procedures or therapies (including therapeutic and other significant radiological procedures); 2) ancillary test and procedures (including 11 radiology ancillary service APGs); or 3) medical visits. Outpatients can be assigned to one or more of the 290 APGs, each comprising a number of clinically and resource intensity-similar procedures, medical visits or ancillary tests. Any new payment methodology for outpatient procedures would broadly impact the radiology community. How radiology providers will fare under the system being proposed will depend on several issues that have not yet been resolved, such as how the basic unit of payment is defined (e.g., a service, a visit, or an episode of care) and whether payment rates will be adequate to compensate for the costs of providing services. One key issue will be whether contrast media and radiopharmaceuticals will continue to be paid as pass-through costs, giving providers the flexibility to choose the specific agent that is most appropriate for their patients.

Ambulatory Care↗
PubMed2006

Understanding recent trends in Swiss ambulatory care utilization when out-of-pocket payment is minimal.

OBJECTIVE: To examine trends in ambulatory care utilization when individuals face almost no financial barriers to health care. METHODS: Observational study of insurance data. Adults with minimal deductible were included. Ambulatory care visits and costs were measured from 1997 to 2002. RESULTS: Mean ambulatory care costs/insuree increased from 1292.- to 1790.- CHF, corresponding to higher increases in drug costs (+61.7 %) than services costs (+24.3 %). The proportion of visits to generalists decreased while those to hospital outpatient services increased. CONCLUSIONS: In a demographically stable population of insurees, increases in ambulatory care costs were due neither to growth in physicians' visits nor to increasing physicians' fees per act, but to what was included in or prescribed during the visits.

Adult↗
PubMed2003

Medicare program, changes to the hospital outpatient prospective payment system and calendar year 2004 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2004. Finally, this rule responds to public comments received on the August 12, 2003 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (68 FR 47966).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2004

Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic.

OBJECTIVES: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care. DESIGN: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996. SETTING: Nonprofit group model HMO. PARTICIPANTS: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic. INTERVENTION: Monthly group meetings held by patients' primary care physicians. MEASUREMENT: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs). RESULTS: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups. CONCLUSION: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status.

Activities of Daily Living↗
PubMed2001

Managing up to maximize medicare reimbursement for outpatient care.

An example of managing up through participation in a multidisciplinary team tasked with maximizing reimbursement under the Medicare ambulatory patient classification (APC) system is described. Medicare's new system of payment for hospital outpatient services replaces the cost-based reimbursement model of the past with a technical payment based on the outpatient evaluation and management level. Individual institutions are responsible for developing criteria for defining technical visit levels. Managers at the New England Medical Center formed a team to develop these criteria. The team outlined components of the patient visit that qualified as technical costs, such as the use of space at a facility, medical and surgical supplies, and nonphysician professional services. Team members then contacted each of the center's clinics to identify specific services that met these criteria. After formulating the technical visit level criteria, the team determined who would assign the technical visit level, wrote policies and procedures, and trained staff. The APC team also assessed billing procedures, focusing particularly on the accuracy of the charge master and the use of proper codes and billing units for pass-through drugs. The team continues to monitor its results by reviewing payments received from Medicare and auditing high-risk areas. The APC team used the principles of managing up to maximize Medicare reimbursement for outpatient visits.

Ambulatory Care↗
PubMed1977

One third of a million days of care at home, 1959 to 1975.

Although articles on studies of organized home care programs are numerous, reports of long-term effectiveness of these programs are scanty. While government spokesmen appear to advocate more widespread use of alternatives to hospitalization, there has been serious criticism of the efficiency and accomplishments of home care services. A medically oriented home care program in Saskatoon (population, less than 150 000) has grown steadily over a 16-year period and is now serving a daily average of 200 individuals. All patients have required "hospital-like care" at home and most have not ordinarily been sufficiently mobile during their time in the program to attend hospital outpatient services. Many have required "concentrated care" through daily visits of professional health personnel. The program is designed for the physically ill and disabled and is administered by the major teaching hospital in the city, although it provides services to the whole community. Over one third of the patients referred in recent years had been at home. Almost one half of the patients have undergone satisfactory rehabilitation at home. The program has also proven to be an acceptable alternative to long-term institutional care for the permanently seriously disabled, a large number of whom are elderly. The program has been able to operate at considerably less cost to the public than inpatient (hospital or institutional) services would have entailed.

Consumer Behavior↗
PubMed2004

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2005 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. In addition, the final rule with comment period describes final changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2005. In this final rule with comment period, we are responding to public comments received on the January 6, 2004 interim final rule with comment period relating to MMA provisions that were effective January 1, 2004, and finalizing those policies. Further, we are responding to public comments received on the November 7, 2003 final rule with comment period pertaining to the ambulatory payment classification assignment of Healthcare Common Procedure Coding System (HCPCS) codes identified in Addendum B of that rule with the new interim (NI) comment indicators (formerly referred to as condition codes).

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