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Biomedical subjects

E R Becker

Publications and source records attributed to E R Becker.

At least 37 records · Page 2Linked to original sources
PubMed1998

Returns on investment in public health: effect of public health expenditures on infant health, 1983-1990.

In this study, we developed a broad conceptual framework focusing on how public health expenditures impact the nation's health. We then applied this framework to infant health outcomes and, using an eight-year state panel database, empirically analyzed how state public health expenditures, ceteris paribus, impact a state's level of teenage births and the receipt of prenatal care. Two hypotheses were tested. Hypothesis 1 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease births to mothers less than 20 years of age. Hypothesis 2 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease the number of infants whose mothers received late or no prenatal care. We find support for both hypotheses but observe that the way public health expenditures are measured has an impact on the findings. Other important implications of the study are noted. To our knowledge, this is the first article that has taken an aggregate state perspective over time and applied it to specific measures of infant health.

Adolescent↗
PubMed1997

Economic winners and losers after introduction of an effective new therapy depend on the type of payment system.

An effective therapy for a costly illness has economic consequences. There may also be differences between provider costs and payer costs and initial versus long-term costs; costs may also vary with the reimbursement scheme. Consider the case of an effective therapy to prevent restenosis after coronary angioplasty. Assume that the initial provider cost of angioplasty is $12,000 and that restenosis within 6 months results in repeat angioplasty in 20% of cases, with a follow-up cost of $2,400, or $14,400 total. Assume that a therapy costs $1,000 per angioplasty and decreases restenosis by 50%, resulting in repeat angioplasty in 10% of cases. This will result in an initial cost of $13,000 and a follow-up cost of $1,300, or $14,300 total. The total societal costs will be -$100, a slight savings. Thus, the $1,100 cost of therapy is offset by reduced costs associated with restenosis, and the societal costs are almost neutral. Assume that under fee for service providers charge costs plus 10% and that without the new therapy either a package price or a capitated system is revenue neutral. Changes in costs resulting from therapy to prevent restenosis are as follows (plus sign indicates cost or loss; minus sign indicates savings or profit): [table: see text] Under fee for service, the payer takes the risks, and the economic consequences to providers are minimal. The situation is reversed under capitation. For whoever takes the risk, there is an initial loss to pay for the therapy, but a long-term gain due to less restenosis. Under package pricing, the providers lose because of the cost of therapy and fewer procedures, while the payers gain. A new therapy, even if it is revenue neutral to society overall, may have considerable economic consequences, which vary with time and with the different perspectives of providers and payers.

Angioplasty, Balloon, Coronary↗
PubMed1996

Cost and therapeutic modification of intracoronary ultrasound-assisted coronary angioplasty.

Intracoronary ultrasound is used to define plaque morphology and quantitative characteristics before and after coronary angioplasty. The cost of the technique was defined in 87 patients who underwent elective, noncomplex procedures: group A was composed of 37 patients without intracoronary ultrasound, who served as a control group; group B comprised 23 patients who had only postcoronary angioplasty ultrasound; and group C was 27 patients who had pre-and postangioplasty ultrasound. Economic analysis was done for the hospital ("bottom-up" methodology of equipment, supplies, support personnel, post-PTCA room) and physician costs (using resource-based relative value scale). The cost in the cardiac catheterization laboratory was: group A = $3,679 +/- $688; group B = $4,650 +/- $457; and group C = $5,301 +/- $835, p < 0.0001. The postprocedure cost for all groups was similar. The total cost was: group A = $5,326 +/- $1,135; group B = $6,815 +/- $1,276; and group C = $7,240 +/- $1,494, p < 0.0001. Intracoronary ultrasound modified the coronary angioplasty procedure in 36% of patients. Precoronary angioplasty intracoronary ultrasound defined the luminal diameter, precluding the use of additional balloons, and thus decreased the cost approximately $650. Use of ultrasound after the procedure increases the cost approximately $200 as a result of performing additional interventions. For intracoronary ultrasound to be economically viable, the change in angioplasty technique will need to be accompanied by improved clinical outcome.

Angioplasty, Balloon, Coronary↗
PubMed1996

Emory University Center for Clinical Evaluation Sciences: a model for clinical practice evaluation in the changing environment of the academic health center.

Changes in the health care marketplace have had a profound effect on academic health centers and their traditional missions: teaching, patient care, and research. Many academic health centers have recognized the need to develop a capability for evaluating clinical practices and organizational restructuring. The Center for Clinical Evaluation Sciences at Emory University represents a model for the integration of evaluative capabilities into academic clinical practices.

Academic Medical Centers↗
PubMed1995

Validating the Resource-Based Relative Value Scale cross-specialty alignment. A survey of double-boarded physicians.

In 1992, Medicare changed significantly how it paid physicians: instead of basing payment rates on charges, the federal government established a fee schedule based on the Resource-Based Relative Value Scale (RBRVS). Central to the development of the RBRVS was the methodology used to align the work of all specialties onto a single, common scale, termed "cross-specialty alignment." This article presents the methods and results of an alternative approach to cross-specialty alignment. We surveyed physicians who were board certified in both pathology and internal medicine (double-boarded) and asked them about the work of services in both specialties. The results provide a natural bridge between the work of the two specialties. The double-boarded survey results agreed closely with the RBRVS findings. Furthermore, the findings were robust after weighting the estimates by how frequently a physician performs a service or after grouping the physicians by the mix of services in their practice. We conclude that the relative work positions of pathology and internal medicine in the RBRVS have validity. Our findings suggest that a survey of physicians with expertise in multiple specialties is a useful approach for developing cross-specialty linkages for an RBRVS or for validating existing linkages.

Adult↗
PubMed1995

A prospective randomized trial comparing the benefits and limitations of 6Fr and 8Fr guiding catheters in elective coronary angioplasty: clinical, procedural, angiographic, and economic end points.

OBJECTIVES: To determine the relation between guiding catheter size, procedural and angiographic details, and cost of coronary angioplasty. BACKGROUND: Miniaturized angiographic equipment used during coronary angioplasty is proposed as a method to decrease the duration of supine bed rest, length of hospital stay, and cost of expensive inpatient hospitalization. METHODS: One hundred and sixty patients were randomized to undergo elective coronary angioplasty with a 6Fr (external diameter, 0.079-in; internal diameter 0.062-in) or 8Fr (external diameter, 0.105-in internal diameter, 0.078-0.079-in) guiding catheter. Standard balloon dilatation catheters were used. END POINTS: 1 degree peripheral vascular complications, 2 degree technical and procedural outcomes; quantitative and qualitative quality of the coronary angiograms; and the in-hospital ("bottom up" cost accounting of equipment, supplies, support personnel, postcoronary angioplasty room), and physician cost (using Resource Based Relative Value Scale). RESULTS: There was no difference in peripheral vascular complications between the two groups (6Fr, 21%; 8Fr, 30%; P = NS). Less contrast medium was used with the 6Fr guiding catheters (6Fr, 178 +/- 102 mL; 8Fr, 257 +/- 147 mL; P = 0.0001). The qualitative quality of the angiograms was better with 8Fr than with 6Fr guiding catheters. For the entire population, the total cost of coronary angioplasty was less with 6Fr guiding catheters ($3,956 +/- $2,415) than with 8F guiding catheters ($5,073 +/- $3,985, P = 0.03). Excluding patients with either a coronary or peripheral vascular complication, there was less cost savings (6F, $3,720 +/- $1,338; 8F, $4,376 +/- 2,699, P = 0.05). Independent variables associated with increased cost included: large body mass index; hypercholesterolemia; nonionic contrast media; 8F guiding catheter; complex lesions; and duration of procedure. CONCLUSIONS: The use of smaller guiding catheters led to use of less contrast medium with a modest decrease in angiographic visualization. The cost savings seen with 6F guiding catheters is multifactorial due to smaller arteriotomy accompanying sheath insertion and reduced rate of clinically significant coronary and peripheral vascular complications.

Angioplasty, Balloon, Coronary↗
PubMed1995

A prospective randomized trial of 0.010" versus 0.014" balloon PTCA systems and interventional fellow versus attending physician as primary operator in elective PTCA: economic, technical, and clinical end points.

BACKGROUND: The cost of performing percutaneous transluminal coronary angioplasty (PTCA) is accelerating. The angiographic, clinical, technical, and procedural variables associated with PTCA cost are largely unknown. METHODS: To determine an interrelationship between equipment size, operator experience, and PTCA cost, 50 patients were randomized to have PTCA performed with large (0.014") or small (0.010") balloon systems. A secondary randomization determined the primary operator of the procedure; either experienced attending physician or inexperienced fellow in interventional cardiology. END POINTS: Primary: PTCA cost (equipment, supplies, support personal, post-PTCA room, and physician (utilizing resource-based relative value scale); Secondary: measures of technical procedural and clinical outcome. RESULTS: The total cost of the PTCA was $4,047 +/- $2,133 for 0.010" systems versus $3,451 +/- $1,004 for the 0.014" systems, P = NS. Independent variables associated with increased cost included: age, diabetes, and duration of procedure in the cardiac catheterization laboratory. There was no significant difference in procedural duration, complications, or outcome between the smaller or larger PTCA catheter systems, and, the less experienced PTCA operator required additional fluoroscopic time to cross the lesion, as well as procedure time compared with the attending physician. CONCLUSIONS: Neither miniaturization of equipment size nor primary operator experience led to PTCA cost savings. Clinical and procedural characteristics are independently correlated with increased PTCA cost. Additional study is needed to determine the exact determinants of PTCA cost, in order to stabilize the cost of this procedure.

Aged↗
PubMed1994

Predicting hospital costs for first-time coronary artery bypass grafting from preoperative and postoperative variables.

To predict hospital costs after coronary artery bypass grafting (CABG) from preoperative characteristics and postoperative complications, 4 analyses of the data were used: (1) a univariate analysis of each preoperative and postoperative variable, (2) a multivariate analysis of the preoperative variables (model 1), (3) a multivariate analysis of the postoperative variables (model 2), and (4) a multivariate analysis of pre- and postoperative variables (model 3). Eight-hundred seven patients who underwent a first-time CABG at Emory University during 1990 were analyzed in this study. Using model 1, the determinants of costs were higher angina grade (p = 0.0006), previous myocardial infarction (p = 0.0133), older age (p = 0.0001), congestive heart failure (p = 0.0001), and a higher number of diseased vessels (p = 0.0001). For model 2, the determinants of costs were adult respiratory distress syndrome (p = 0.0073), intraaortic balloon pumping (p < 0.0001), pneumonia (p < 0.0001), septicemia p < 0.0001), major arrhythmia (p < 0.0001), reexploration for bleeding (p < 0.0001), wound infection (p = 0.0632), neurologic event (p = 0.0013), fluid overload (p = 0.0516), and absence of pericarditis (p = 0.0588). For univariate analysis, the determinants of increased costs were similar to those from models 1 and 2. Although there is considerable variance in hospital costs for any number of complications, utilized resources (costs) increase inexorably as patients have more complications after coronary surgery. The mean cost to the hospital for the 382 patients who underwent CABG and experienced no complications was $16,776.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Artery Bypass↗
PubMed1994

An introduction to clinical microeconomic analysis: purposes and analytic methods.

The recent concern with health care economics has fostered the development of a new discipline that is generally called clinical microeconomics. This is a discipline in which microeconomic methods are used to study the economics of specific medical therapies. It is possible to perform stand alone cost analyses, but more profound insight into the medical decision making process may be accomplished by combining cost studies with measures of outcome. This is most often accomplished with cost-effectiveness or cost-utility studies. In cost-effectiveness studies there is one measure of outcome, often death. In cost-utility studies there are multiple measures of outcome, which must be grouped together to give an overall picture of outcome or utility. There are theoretical limitations to the determination of utility that must be accepted to perform this type of analysis. A summary statement of outcome is quality adjusted life years (QALYs), which is utility time socially discounted survival. Discounting is used because people value a year of future life less than a year of present life. Costs are made up of in-hospital direct, professional, follow-up direct, and follow-up indirect costs. Direct costs are for medical services. Indirect costs reflect opportunity costs such as lost time at work. Cost estimates are often based on marginal costs, or the cost for one additional procedure of the same type. Finally an overall statistic may be generated as cost per unit increase in effectiveness, such as dollars per QALY.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Disease↗
PubMed1994

Hospital resource utilization during coronary artery bypass surgery.

OBJECTIVE: To predict hospital resource utilization for coronary surgery (CABG) from preoperative characteristics and to determine the influence of previous CABG on the results. DESIGN: Two analyses of the data were used to predict hospital costs: 1) a univariate analysis of each preoperative variable; and 2) a multivariate analysis of preoperative variables, and interaction terms with previous CABG. PATIENTS: A sample of 418 patients who received CABG at Emory University during 1990. RESULTS: From the multivariate analysis, the determinants of costs were previous CABG (P = 0.0653), female sex (P = 0.1005), diabetes (P = 0.0805), older age (P = 0.0062), and a combination of previous CABG with female sex (P = 0.0017), previous myocardial infarction (P = 0.0636), low ejection fraction (P = 0.0001), and younger age (P = 0.0363). For the univariate analysis, the determinants of increased costs were similar to those from the multivariate analysis. CONCLUSION: The correlation between patients with potential medical difficulties or previous cardiovascular surgery show a positive impact on higher hospital costs.

Age Factors↗
PubMed1992

The impact of the Texas 1989 motorcycle helmet law on total and head-related fatalities, severe injuries, and overall injuries.

The State of Texas implemented a mandatory total motorcycle helmet law for all operators and passengers, effective September 1, 1989. In this study the impact of this intervention on frequency of both total and head-related fatalities, severe injuries, and overall injuries for operators during the subsequent year was quantified. This quantification is important because 26 states in the United States fail to have strict, mandatory helmet laws. The Box-Tiao time-series intervention methodology is used to estimate secular trends before and changes after the implementation of the law, analyzing Department of Public Safety monthly injury accident data for a period of 6 years collected from traffic accident reports filed for each motorcycle injury accident. Trends in fatalities and injuries (except for head-related deaths) estimated before implementation of the law approximated the 9.4% average annual decline in motorcycle registrations. Additional declines of 12.6% and 57.0%, respectively, were estimated for total and head-related fatalities during the year after the law was implemented. Declines of 13.1% and 54.6% were estimated for severe injuries for total and head-related accidents. Declines of 12.3% and 52.9% were found for total and head-related injuries overall.

Confidence Intervals↗
PubMed1992

An overview of the development and refinement of the Resource-Based Relative Value Scale. The foundation for reform of U.S. physician payment.

Responding to distortions in payment rates between services, policymakers in the United States have sought a systematic and rational foundation for determining physician fees. One such approach to paying physicians, the Resource-Based Relative Value Scale (RBRVS), determines fees by measuring the relative resource costs required to produce them. On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the RBRVS. This article provides a brief history of the RBRVS and a summary of the methods and data used to derive it. This overview represents the culmination of 6 years of research by the Harvard RBRVS study team and provides a road map to the study's concepts and definitions. The overview also provides a context for the articles in this issue that describe five major studies undertaken since 1988. The study's overall results are presented in the last article of the series.

Data Collection↗
PubMed1992

Incorporating practice costs into the Resource-Based Relative Value Scale.

Practice costs (not including liability insurance costs) account for approximately 41% of the payment for medical and surgical services in the Medicare Fee Schedule. Unlike the portion of the fee schedule that compensates physicians for their work, the practice cost portion of the Medicare Fee Schedule is not resource-based; it is based instead on historical charges. As a result, physicians can recover their practice costs in less time and with less effort (measured in work relative value units) by performing invasive procedures and tests than by providing evaluation and management services. The Physician Payment Review Commission has proposed, in some detail, a method for incorporating practice costs into the Medicare Fee Schedule. The method involves allocating indirect costs on the basis of physician work plus direct costs. We find, using their own analytical framework, that indirect costs should rather be allocated on the basis of time. But to better serve the goal of incentive neutrality, and to make practice cost payments more equitable, the payment a physician receives for practice costs should be based not on service mix and volume, but on characteristics of the physician's practice more closely related to practice costs: for example, whether the physician has an office, or whether the physician practices alone or in a group.

Cost Allocation↗
PubMed1992

Results and impacts of the Resource-Based Relative Value Scale.

On January 1, 1992, the Health Care Financing Administration implemented the 1989 legislation reforming the Medicare payment system for physicians' services. The cornerstone of the new payment reform is the Medicare Fee Schedule (MFS), which is based on the Resource-Based Relative Value Scale (RBRVS). In this article, the major findings of the RBRVS study and its impacts on physician payment are summarized. The authors report the impacts of a RBRVS-based fee schedule on Medicare fees and physicians' income if it were fully implemented, assuming budget neutrality and absence of volume changes in services. Under this scenario, fees for evaluation and management services increase by 15% to 45%, while fees for invasive services and diagnostic tests decrease by 20% to 30%. These changes increase the Medicare income of family practitioners by more than 30% while decreasing the income of most surgical specialties by 10% to 20%.

Economics, Medical↗
PubMed1992

Physician payment reform: how will medical specialties fare under the new Medicare fee schedule?

In 1989, the federal government legislated a major overhaul of the Medicare payment system for physician services, to be implemented beginning in January 1992. Under the new plan, payments will be set according to a national fee schedule based primarily on a "resource-based relative value scale." This article summarizes the development of the new payment system and explores the likely impact of its implementation on medical and surgical specialties.

Economics, Medical↗