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Biomedical subjects

F R Curtiss

Publications and source records attributed to F R Curtiss.

At least 19 recordsLinked to original sources
PubMed1990

Managed care: the second generation.

The current status of managed health care is described and its impact on hospital and pharmacy operations is summarized. In the 1980s, managed care evolved into a three-segment industry, comprising health maintenance organizations (HMOs), preferred-provider organizations, and fee-for-service plans. Five new trends are emerging as managed care, now an established part of the country's health-care delivery system, enters its second generation: dual- and triple-option plans with financial risk sharing between employers and insurers/HMOs, point-of-service determination of benefits and coverage, consolidation of the number of options offered by employee health plans, creation of exclusive provider organizations, and direct provider contracting. Persons charged with negotiating managed-care contracts will make use of three primary cost-management methods: benefit design, provider reimbursement, and prospective pricing. Employees will take an increasingly active part in purchase decisions. Enrollees will face tradeoffs between their desire for maximum freedom of choice of provider and higher premiums, deductibles, and out-of-pocket expenses. Managed-care plans will continue to have a strong impact on hospitals, especially in the areas of reimbursement and use review. The effect of managed care on pharmacy operations will vary from institution to institution; among the positive results may be increased appreciation of the role of clinical pharmacy services in reducing the incidence of readmissions and the length of hospital stays. The result of these changes in the structure of health-care benefits will be greater price sensitivity, marked by a suppression of unnecessary use of health-care services and an increased tendency to compare and evaluate health-plan costs.

Health Maintenance Organizations↗
PubMed1989

Managed health care.

The fundamental components of managed-care plans are described; the development of managed-care programs is discussed; and the impact of managed care on pharmacy services and the price, quality, and accessibility of health care are reviewed. Health care can be considered to be managed when at least one of the following fundamental components is present: prospective pricing, "UCR" (usual, customary, and reasonable) pricing of services, peer review, mandatory use review, benefit redesign, capitation payments, channeling, quality criteria, and health promotion. The managed-care industry consists of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and managed fee-for-service plans. Managed-care reimbursement principles involve transferring some or all of the impetus for controlling use of services to the health-care provider. Means by which this is done include prospective pricing, services bundling, price discounts and negotiated fees, and capitation financing and reimbursement. Financial risk-sharing arrangements with providers--including hospitals, physicians, pharmacies, and home-care companies--are necessary for any managed-care plan to attain true control over its service costs. Use-review and use-management services are also fundamental to containing health-care spending. These include retrospective, concurrent, and prospective reviews of the necessity and appropriateness of medical services. Use management, like services bundling and prospective pricing, has been more effective in reducing costs of hospital inpatient services than costs associated with ambulatory care. Per case payments and services bundling have made individual charges for items irrelevant to hospital revenue. This has forced hospital pharmacy managers to become more sensitive to cost management. Drug formularies, improved productivity, and use of prescribing protocols are means by which hospital pharmacies have controlled costs. However, since shorter hospital stays are not associated with a linear decline in the need for drug therapy, reducing pharmacy operating expenses in proportion to the decline in hospital occupancy is probably not possible. Community pharmacies have responded to managed care by forming pharmacy services administrative organizations. Application of managed-care principles has reduced the use of inpatient hospital services by Medicare beneficiaries, helped HMOs and PPOs to lower prices for some services, reduced use of hospital services by HMO members, and redirected some inpatient hospital care to alternate-care providers.(ABSTRACT TRUNCATED AT 400 WORDS)

Capitation Fee↗
PubMed1988

Recent developments in federal reimbursement for home health-care services and products.

The current status of reimbursement for home health-care (HHC) products and services is described, and the influence of competition and consolidation on the HHC industry is discussed. Despite inadequate financing and reimbursement pressures, the demand for HHC services continues to grow. The degree of competition in the HHC industry is reflected in bundling of services (gathering payments for services into a single per-capita rate), prospective price negotiations, and competitive bidding. This competition within the home-care industry and pressure on operating margins have spawned a flurry of recent mergers, acquisitions, and corporate restructuring. HHC agencies and suppliers, particularly durable medical equipment suppliers, have been squeezed by inadequate Medicare cost-finding methods, low reimbursement rates, and a high number of denials of Medicare coverage. Three important recent federal measures revised definitions of Medicare coverage, established minimum and maximum payment periods for Medicare reimbursement, reduced payments for services and products covered under Medicare Parts A and B, resurrected prospective-pricing demonstration projects, reduced payments for durable medical equipment and home oxygen supplies, and expanded coverage of services for AIDS patients. State Medicaid program budgets are threatened by recurring administration proposals to cap federal matching payments and by the adoption of a competitive-bid approach to health-care contracting. To survive over the next few years, home health agencies and home-care suppliers will need to monitor operating costs even more closely and pay attention to the patient (payer) mix.

Competitive Bidding↗
PubMed1987

Pharmacy preferred-provider organizations.

The structure, features, and evolution of pharmacy preferred-provider organizations (PPOs) are described. Pharmacy PPOs may be sponsored by insurers, employers, providers, or independents (wherein the PPO functions as a third-party administrator); insurer and provider sponsorship are the most common. The advantages and disadvantages of these four types of sponsorship are described. Ways that pharmacy PPOs contain costs include the following: using drug product selection formularies (wherein providers are paid at prospective prices for generic products, regardless of the product dispensed or prescribed), reducing drug use by employing use-review mechanisms, and eliminating fraud and abuse through audits. Another cost-management feature being planned is the use of prescribing protocols. PPOs benefit pharmacies by increasing patronage and traffic flow, protecting market share, and improving cash flow by expediting payment of claims. Factors to consider in choosing a pharmacy PPO include the organization's market share, financial health, payment record, quality of claims processing, and long-term goals. As the pharmacy PPO industry matures, PPO financing will evolve from fee-for-service arrangements to moderate-risk contracting to full-risk contracting with plan buyers, using a negotiated amount per subscriber per month. Increasing competition and adoption of a credentialing process should result in more specific quality-of-care and performance standards for pharmacy PPOs.

Cost Control↗
PubMed1986

Financing home health-care products and services.

Factors affecting growth of the home health-care (HHC) industry are identified, basic principles of HHC product and service reimbursement are reviewed, and third-party payer coverage criteria and payment methods for HHC products and services are discussed. Reimbursement for HHC services has suffered from the absence of a financing mechanism for long-term care. Providers of HHC services are burdened by the laborious process of obtaining favorable coverage determinations for short-term-care patients when home care substitutes for institutional care. When home care is covered benefit, there is often a complex mix of confusing coverage rules, coverage criteria that differ among public and private payers, and interpretations of coverage criteria that differ among local carrier personnel. Private financing obstacles and federal budget deficits will deter the development of an adequate financing mechanism for HHC. The growth of health-maintenance organizations and competitive medical plans will help to reduce reimbursement complexity. Long-term changes in HHC financing may become less important if capitation payment is successful.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1986

Recent developments in federal reimbursement for home health care.

Important recent changes in federal reimbursement for home health-care (HHC) services are discussed, and practical suggestions for dealing with these changes are offered. Regulatory changes affecting Medicare are generally directed at controlling HHC expenditures through more restrictive coverage criteria and lower payment rates. Both HHC agencies and HHC suppliers have been affected by recent regulatory developments, many of which have emanated from the program initiative work group (PIW) cost-control program implemented by HCFA. Regulatory changes in Medicaid have emphasized the substitution of home care for institutional care, particularly skilled-nursing-facility care. Private payments for HHC will likely be tied to capitation programs in which employers will contract directly with health-care organizations (such as health-maintenance organizations) to provide comprehensive services to employees and dependents. Until capitation financing becomes predominant, providers of HHC will be forced to contend with myriad carriers and insurance companies, each of which has its own coverage criteria and its own method of interpreting those criteria. Provider success will depend upon obtaining timely and favorable coverage determinations for prospective patients, establishing strong referral ties with physicians and discharge planners, being selective in the scope of services offered and the types of patients accepted, and keeping abreast of the regulatory changes that affect coverage and payment for HHC products and services.

Costs and Cost Analysis↗
PubMed1986

Recent developments in organizing and financing health-care services.

Recent developments in the organization and financing of health-care services are described. All recent developments reflect an effort by both private and public payers to restrict use of health-care services, as well as to control price. Private use-review programs, such as second-surgical-opinion services and case-management services, are increasingly being used. The number of hospital admissions and length of patient stay continue to decline, but, because of increasing complexity of care, the cost of pharmaceutical services has not decreased proportionately. Points relating to health-care financing in the federal reconciliation budget effective May 1, 1986, are reviewed, as are other new federal regulations affecting the structure of services and terms of reimbursement under the Medicare and Medicaid programs. For Medicare, these include new scope objectives for professional review organizations, decreased return-on-equity payments to for-profit hospitals for outpatient services and to skilled nursing facilities, and elimination of waiver-of-liability presumptions for hospitals. Also, physicians must now identify specific services provided during each inpatient hospital visit. Most developments related to home health-care services pertain to limiting the cost of durable medical equipment. Alternative types of health care based on capitation funding, such as health maintenance organizations, competitive medical plans, and preferred provider organizations, will continue to grow in both the public and private sectors, and the use of private use-review programs for controlling costs is expected to accelerate in the next year.

Delivery of Health Care↗
PubMed1986

Methods of providing prescription drug benefits in health plans.

Drug-benefit programs in health plans that offer varying degrees of risk to pharmacy providers are described. Administrators of health plans attempt to control the total cost of a drug benefit by controlling the cost per prescription, number of prescriptions, and administrative expenses. Specific ways to control these factors, such as through discounted product costs, patient copayments, and audits of prescribing practices, are described. Drug-benefit programs generally follow one of three models: fee-for-service contracts, hybrid fee-for-service risk contracts, and full-risk contracts. Examples of plans within each model are described. Full-risk contracts that provide drug benefits on a capitation basis put pharmacy providers at most risk of financial loss since physicians control prescribing. Pharmacists can control their risk by establishing a joint pharmacist and physician prescription fund that includes contract provisions limiting maximum losses, defining exceptions to the drug benefit, and paying close attention to payment schedules and characteristics of the program administrator. Antitrust issues associated with these new types of drug-benefit plans are described. Drug-benefit programs involving risk contracts can aid pharmacy practice by improving cash flow via negotiated prepayments, defining an enrolled patient population, and creating opportunities for generating additional revenue. Drug-benefit programs involving full-risk contracts and hybrid fee-for-service risk contracts will continue to develop, and understanding these models is the first step toward successful risk contracting by pharmacists.

Contract Services↗
PubMed1986

HMO, CMP, or PPO?

Explore the source record for details and available documents.

Economic Competition↗
PubMed1985

Analysis of nationwide pharmacy charges per DRG.

The national hospital data used by the Health Care Financing Administration (HCFA) to construct the DRG-payment weights for the Medicare prospective-pricing system are analyzed and evaluated. The database represented a 20% sample of all Medicare hospital bills in 1981. Each record contained 96 bytes of data in 28 field elements, including DRG assignment, Standard Metropolitan Statistical Area code, length of stay (LOS), pharmacy charges, and total hospital charges. There was considerable variation in the relative weight of pharmacy charges to total ancillary charges among DRGs; however, the degree of variation appeared to be similar for both rural and urban hospitals. Examination of the pharmacy charges for the top-10 Medicare DRGs revealed that the median pharmacy charge per DRG was consistently less than the average pharmacy charge per DRG. Average pharmacy charges per DRG were generally 50% greater for urban hospitals than rural hospitals. Average and median LOS per DRG also differed substantially, and the LOS for urban hospitals was approximately 20% longer than it was in rural hospitals for all DRGs. The standards derived from the pharmacy-charge and LOS data used by HCFA in developing the DRG-payment weights should be used cautiously. The heterogeneity of these data confirms the imprecision in constructing these weights and the need to use median rather than average statistics as standards in use-review programs.

Costs and Cost Analysis↗
PubMed1984

Final regulations on Medicare prospective pricing.

The final regulations implementing the Medicare prospective pricing system, published by the Health Care Financing Administration in January 1984, are reviewed. The regulations differ from the proposal published in September 1983 in that payments for "outlier" cases and the regional standardized payment amounts were reduced. Also, hospitals were granted a bit more flexibility in billing Medicare beneficiaries under certain conditions. Five functions of peer review organizations that will monitor this system are also described: (1) admissions review, (2) outlier review, (3) procedure review, (4) DRG validation, and (5) quality review. Hospital pharmacy managers need to be aware of the financial incentives inherent in these recent hospital reimbursement changes.

Medicare↗
PubMed1984

Reimbursement dilemma regarding home health-care products and services.

Reimbursement mechanisms for home health-care products and services are discussed in detail. The two major categories of the home health-care industry--(1) skilled nursing, homemaker, and other services, and (2) equipment, supplies, and other products (including drugs)--are reimbursed by third-party payers differently. While prospective pricing of inpatient care encourages the growth of home-care services, government administrators are concerned about potential spending growth at a time of ballooning deficits, and private health insurers are uncertain about coverage criteria. Nuances of Medicare coverage criteria and private insurance reimbursement for home health-care services are described. Medicaid coverage of drugs and biologicals for home patients is also described. The Health Care Financing Administration (HCFA) is expected to clarify and restrict Medicare coverage and payment of home-care products, equipment, and supplies. Medical justification will probably become more specific with greater attention to patient diagnoses and prognosis of patient therapies. Per-case payment methods will be refined to encompass home care. The government and private insurance programs will move toward capitation payment methods under which institutions will have even greater incentives to develop sophisticated home-care programs to substitute for institutional care.

Enteral Nutrition↗