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This final rule implements, without embellishment or additional requirement, the recently enacted statutory authority to collect Social Security account numbers from all DoD beneficiaries as part of the program to identify third party payer situations.
Three panelists at the featured plenary session--Uwe Reinhardt, PhD, Richard Kronick, PhD, and Ronald Rouse--examined whether health policy-makers and the public are prepared to consider an all-payer system as a way to reform the American health care system.
Two of the three "P"s--payers and purchasers--have recently begun forming exclusive contract relationships specifically to control healthcare costs. The irony is that the excluded "P," providers, has the most direct influence over the costs of patient care. This article, the fifth in a six-part series on "managing managed care," focuses on ways for hospitals to deal with these employer initiatives.
The techniques used to exercise control over billed fees and the resulting customary charge profile constitute the physician's third-party payer relations program. Here are the key elements of an effective program.
This notice describes how section 9319 of the Omnibus Reconciliation Act of 1986 (Pub. L. 99-509) affects the Medicare Program. Section 9319---Makes Medicare secondary for services furnished to disabled beneficiaries who are "active" individuals and are covered under large group health plans; Provides that the Federal Government may recover double damages from group health plans that fail to make primary payments as required by the law; Creates a private cause of action which provides double damages from primary payers that fail to make primary payments as required by the law; Provides special enrollment periods so that Medicare coverage can be restored promptly when group health plan coverage terminates; and Provides that in computing premium increases for late enrollment, periods of large group health plan coverage be excluded. The statutory changes made by section 9319 do not require regulations to implement because they are clear on their face as to what the Congress intended. Thus, we can put them into effect without first issuing regulations. Moreover, we have already had to apply these provisions because the congress made these changes applicable to services furnished on or after January 1, 1987. This notice will help to ensure that all affected parties are aware of the new provisions. This notice is not intended to be an exhaustive list of the changes, nor is it intended to represent the complete text of section 9319.(ABSTRACT TRUNCATED AT 250 WORDS)
Estimates based on 1980 data indicate that almost two-thirds of the disabled elderly in New York City receive care only from informal sources. Another one-fifth use a combination of informal and formal sources of care. Thus, only about 15 percent are exclusively dependent on various agencies and programs that constitute the formal home care system. Over 200 organizations in 1986 offered some form of home care service in New York City. Among these were at least 100 proprietary businesses, 61 nonprofit personal care agencies, and 36 nonprofit certified home health agencies. In 1984, 166,739 different New York City residents received home care services provided by the four largest types of formal providers of care: certified home health agencies; Long Term Home Health Care Programs; Human Resources Administration home attendant agencies and homemaker/housekeeper agencies; and Department for Aging homemaker/housekeeper programs. While women age 65 and older living alone are the largest client group for home care services, persons below age 65 account for approximately one-fourth of program caseloads of the four major home care providers in New York City. An estimate of one-day home care use in 1984 shows that the four major types of providers served 59,554 persons with total annual expenditures of $499.3 million, while nursing homes cared for 36,072 persons with annual expenditures of almost $1.4 billion. It is thus evident that more people are receiving organized, extended care at home on a given day in New York City than in nursing homes. Medicaid, the major payer for home care in New York City, spent $412.4 million on home care services in 1984, accounting for 82.6 percent of total publicly funded expenditures for home care services. Of this amount, 89 percent was for personal care services provided through the Human Resources Administration's personal care program. More details on home care in New York City follow, along with a discussion of policy perspectives surrounding the provision of and payment for home care services in the future.
Data Library: What effect will managed care penetration have in your area of the country? Fewer patient days, fewer beds, fewer discharges? What toll will managed Medicare and Medicaid take? This month's column looks at projections on the effects of managed care on inpatient utilization by payer and by region. Some areas of the country might be alarmed by the numbers.
Growth hormone (GH) therapy has an established record of efficacy in the treatment of children with proven GH deficiency. It has also shown benefit, including nongrowth-related benefit, in other nontraditional pediatric uses, but managed care plans hesitate to reimburse clinicians for such uses. In adults and in those individuals who are in transition from GH-deficient children to adults, GH deficiency is sometimes difficult to diagnose. In such cases, growth rate cannot be used to guide therapy and the outcomes measures are either "softer" (e.g., quality of life) or very long term (e.g., bone mineral density changes). Also, there are no long-term data to show GH treatment in adults affects the cardiovascular-associated morbidity and mortality from GH deficiency. However, several cardiovascular risk factors, such as hypercholesterolemia and abdominal adiposity, improve in GH-deficient adults who receive GH treatment. Clinicians and payers often appear at odds with each other over their primary goals for managing the various forms of GH deficiency. However, upon closer examination, both parties do share common treatment goals and strive to do the right clinical thing. Identifying the cost of treatment emphasizes the need for evidence-based medicine.
International trade and travel have rendered political and geographic boundaries irrelevant when it comes to diseases. HIV and SARS are among the more recent examples of deadly viruses that spread swiftly from one continent to the next before international health experts can identify them, much less begin to search for a cure. This snapshot of global health issues looks at payer systems from a cross section of nations, lists the world's eight most infectious diseases and their rate of incidence by region, and pays special attention to the shortage of health care workers, which has reached crisis proportions in many areas and is pitting nation against nation in the competition for qualified staff.
OBJECTIVE: To determine whether changes in health maintenance organization (HMO) penetration or payer mix affected in-hospital mortality and treatment patterns of patients with acute myocardial infarction (AMI). STUDY DESIGN: Observational study using patient-level logistic regression analysis and hospital and year fixed effects of data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a geographically diverse sample of 20% of the hospitalized patients in the United States. PATIENTS AND METHODS: Discharges of patients (n = 340,064) with a primary diagnosis of acute myocardial infarction who were treated in general medical or surgical hospitals that contributed at least 2 years of data to the HealthCare Cost and Utilization Project Nationwide Inpatient Sample from 1989 to 1996. In-hospital mortality and rates of cardiac catheterization, angioplasty, or coronary artery bypass grafting for Medicare patients or non-Medicare patients were the main outcome measures. RESULTS: Among Medicare patients, increases in HMO penetration were associated with reduced odds of receiving cardiac catheterization, angioplasty, or coronary artery bypass grafting of 3% to 16%, but were not associated with any change in mortality risk. Increases in the number of HMOs within a metropolitan statistical area, our measure of HMO competition, were associated with small but significant increases in the odds of cardiac catheterization and angioplasty of about 2%. There was no pattern of changes in cardiac procedure rates or in-hospital mortality among non-Medicare patients. CONCLUSION: Increases in HMO penetration reduced cardiac procedure rates by statistically significant but small amounts among Medicare patients with AMI, without affecting mortality rates.
The latest challenges to billed charges come from an unexpected source-the hospital's contracted payers. Understanding these challenges, and their legal basis, is important to protecting your hospital's contracts.
Clinical trials form the evidence base for medical decision making and may provide patients with life-threatening conditions their best chance to find an effective treatment. A growing number of states and the federal government are mandating coverage of the routine costs of cancer clinical trials, although the extent of coverage varies. Individual health plans are following suit on behalf of their beneficiaries. Trials conducted at the National Cancer Institute (NCI) are an attractive resource for payers, because NCI provides medical services at no charge, enables patient access to promising care, emphasizes continuity with patients' regular physicians, and makes the referral and enrollment process easy and efficient through its Clinical Studies Support Center's toll-free information line 1-888-NCI-1937.
To investigate the importance of the payer in the utilization of in-hospital cardiac procedures, we examined the care of 37,994 patients with Medicaid, private insurance, or no insurance who were admitted to Massachusetts hospitals in 1985 with circulatory disorders or chest pain. Using logistic regression to control for demographic, clinical, and hospital factors, we found that the odds that privately insured patients received angiography were 80% higher than uninsured patients; the odds were 40% higher for bypass grafting and 28% higher for angioplasty. Medicaid patients experienced odds similar to those of uninsured patients for receiving angiography and bypass, but had 48% lower odds of receiving angioplasty. In addition, the odds for Medicaid patients were lower than for privately insured patients for all three cardiac procedures. These findings suggest that insurance status is associated with the utilization of cardiac procedures. Future studies should determine the implications these findings have for appropriateness and outcome and whether interventions might improve care.
Two prospective payment systems that operated concurrently in New Jersey during 1980-1982 created a natural experiment and a unique opportunity to compare the effectiveness of the two systems in restraining cost increases. Our results indicate that during that period, annual increases in the cost per case were significantly less in hospitals that were subject to the all-payer DRG system than in those institutions that were paid under the Standard Hospital Accounting and Rate Evaluation (SHARE) program. We also found that, relative to the SHARE program, the DRG system appears to have increased admission rates and reduced length of stay.
Each third-party health payer has its own method of determining which medical services should be covered. The new National Center for Health Care Technology (NCHCT) is charged with evaluating the medical and scientific basis for Medicare coverage of various tests and procedures used in the practice of medicine. Many of the important issues involved in performing these evaluations and the NCHCT approach are described in this article.
Cost shifting, in which governments transfer the cost of certain health care services to patients or private insurance companies, is increasing rapidly, and Dr. Christopher Carruthers thinks it will spell an end to Canada's single-payer system. The signs are already there: the private sector is offering more services and employers are keeping a closer eye on the health care system as they begin to pay a bigger share of the costs. The result, says Carruthers, is that government influence is bound to diminish as the private sector tries to fill voids created by governments that are trying to live within their fiscal means.
The relationship between third-party payers and dermatologists is generally governed by a written contract. That relationship can be more beneficial to the dermatologist, and chances of liability may be decreased, both for breach of contract and for malpractice, if the dermatologist pays close attention to the language in the contract. All contracts are generally negotiable; detrimental language in the contract often may be removed or changed. This article presents information to help prepare dermatologists to review and negotiate contracts.
New Jersey's diverse constituencies and special interest groups don't usually agree on a public policy issue. However, almost everyone in the public policy arena agrees that hospitals should treat people who show up in emergency departments with problems requiring medical attention. For over a decade, Garden State policymakers, payers, and providers have faced the dilemma of excess demand on hospitals that treat the uninsured. This demand has risen due to increasing health care costs, development of costly technology, state deregulation of hospital payments, and employers' reluctance to insure workers and their families coupled with a mobile workforce holding part-time and seasonal jobs. The fiscal solvency of inner-city hospitals is threatened yet the problem continues to elude resolution.