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Cadaveric versus living donor kidney transplantation: a Medicare payment analysis.
BACKGROUND: We found previously that the clinical advantages of living donor (LD) renal transplantation lead to financial cost savings compared to either cadaveric donation (CAD) or dialysis. Here, we analyze the sources of the cost savings of LD versus CAD kidney transplantation. METHODS: We used United States Renal Data System data to merge United Network for Organ Sharing registry information with Medicare claims data for 1991-1996. Information was available for 42,868 CAD and 13,754 LD transplants. More than 5 million Medicare payment records were analyzed. We calculated the difference in average payments made by Medicare for CAD and LD for services provided during the first posttransplant year. RESULTS: Average total payments were $39,534 and $24,652 for CAD and LD, respectively (P<0.0001) during the first posttransplant year. The largest source of the difference in payments was in inpatient hospitals, representing $10,653.67 (P<0.0001). For patients who had Medicare as the primary payer, average transplant charges were significantly higher for CAD donation ($79,730 vs. $69,547, P<0.0001); average transplant payments demonstrated no statistical differences ($28,483 vs. $28,447, P = 0.858). Therefore, inferred profitability was significantly higher for LD. CONCLUSIONS: Medicare payments are remarkably lower for LD compared to CAD in every category. The single largest cost saving comes from inpatient hospital services. A portion of the savings from LD could be invested in programs to expand living kidney donation.
Economic burden of revision hip and knee arthroplasty in Medicare enrollees.
UNLABELLED: The economic burden to Medicare due to revision arthroplasty procedures has not yet been studied systematically. The economic burden of revisions was calculated as annual reimbursements for revision arthroplasties relative to the sum total reimbursements of primary and revision arthroplasties. We evaluated this revision burden for total hip and knee arthroplasties through investigation of trends in charges and reimbursements in the Medicare population (Parts A and B claims from 1997-2003), while taking into account age and gender effects. Mean annual economic revision burdens were 18.8% (range, 17.4-20.2%) and 8.2% (range, 7.5-9.2%) for total hip arthroplasties and total knee arthroplasties, respectively. Procedural charges increased while reimbursements decreased over the study period, with higher charges observed for revisions than primary arthroplasties. Reimbursements per procedure were 62% to 68% less than associated charges for primary and revision total hip and knee arthroplasties. The effect of age and gender on reimbursements varied by procedure type. Unless some limiting mechanism is implemented to reduce the incidence of revision surgeries, the diverging trends in reimbursements and charges for total hip and knee arthroplasties indicate that the economic impact to the Medicare population and healthcare system will continue to increase. LEVEL OF EVIDENCE: Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.
A cost comparison of medical management and transurethral needle ablation for treatment of benign prostatic hyperplasia during a 5-year period.
PURPOSE: We performed an analysis comparing the cost of medical management with TUNA therapy for a 5-year period. MATERIALS AND METHODS: Published costs for tamsulosin, finasteride, transurethral needle ablation (TUNA, Medtronic, Inc., Minneapolis, Minnesota) and transurethral resection of the prostate were used to construct a cost analysis model comparing medication with TUNA. The model analyzed monotherapy with an alpha-blocker (tamsulosin) and a 5alpha-reductase inhibitor (finasteride), combination therapy using both medications, and a mixed scenario using monotherapy and combination therapy. Published data were used to estimate the rate of surgical intervention in patients initially treated with medications or TUNA. RESULTS: Tamsulosin monotherapy was less expensive than TUNA for 5 years ($3,485 for tamsulosin vs $4,811 for TUNA year 5). Finasteride monotherapy reaches a break-even point with TUNA during year 5 ($4,867 for finasteride vs $4,811 for TUNA). Combination therapy reaches a break-even point with TUNA after approximately 2 years 7 months of treatment ($4,515 for combination therapy vs $4,572 for TUNA) and the mixed scenario breaks even with TUNA at approximately year 4 ($4,696 for medical management vs $4,645 for TUNA). CONCLUSIONS: The TUNA procedure compares favorably to combination medical therapy for the treatment of benign prostatic hyperplasia on a cost basis. alpha-Blocker monotherapy is less costly than TUNA while 5alpha-reductase inhibitor monotherapy is approximately equivalent to TUNA for 5 years. The TUNA procedure is less expensive than combination medical management for 5 years, with a break-even point at approximately 2 years 7 months.
Rural and urban physicians: does the content of their Medicare practices differ?
Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.
Operational, professional, and business characteristics of radiology groups in the United States.
To learn the main operational, professional, and business characteristics of U.S. radiology group practices, researchers at the American College of Radiology surveyed these groups. Major findings included the following: Approximately 30% of groups provide only diagnostic radiologic services, a similar percentage provides only radiation therapy for oncologic patients, and the remainder provides both types of services. Forty-one percent of groups practice only in hospitals, 11% practice only in an office, and 48% practice in both settings. Diagnostic-only practices average 10,000-12,000 procedures per full-time equivalent radiologist per year. Groups typically require new members to be part of the group for almost 3 years before they become full partners. Formal call schedules are nearly universal among radiology groups. Groups are becoming increasingly involved with health maintenance organizations and other "alternative delivery systems," but fee-for-service remains by far the dominant source of groups' revenue. Most studied characteristics of groups are changing relatively slowly, and trends are generally toward increasing formalization of arrangements.
Managed care and psychotherapy for schizophrenia.
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Physician payment reform: an idea whose time has come.
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Can consumer choice reward quality and economy? Towards a test of economic competition.
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In-home physician visits and large medical groups.
In-home care has grown rapidly in the past decade and has become increasingly complex. Accompanying these changes has been a resurgence of what was once thought to be an endangered if not extinct species, the physician house call. This paper is concerned with the involvement in the provision of physician home visits by large medical groups, and with how this involvement is related to the characteristics of the medical group. In December 1989, telephone interviews were conducted with 174 large medical groups (those with more than 50 physician members), representing a response rate of 73 percent of the universe of (239) groups found to fit study criteria. Of responding groups, 52 percent indicated that they provided physician home visits. Groups in states with higher proportions of population aged 85 years and over and groups that report accepting physician house calls are more likely to provide house calls. It is concluded that the provision of house calls by large medical groups is likely to increase with the greater complexity of in-home care, the shift of acute care into the home, and the rapid growth of the very old population.
Commentary on the closing of a social health maintenance organization.
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Comparing urban and rural physicians.
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Doctors' views of Medicare payment levels.
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A crime story from Medicare Part B.
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Perspectives on physician payment reform.
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Medicare: trends in reimbursing hospital dental practices.
A survey of dentists working in hospitals found that dental procedures covered under Medicare are not equally reimbursed. Lack of uniform guidelines, appropriate interpretation and universal claim forms lead to problems. Most respondents favor medically adjunctive dental care in the national health care reform.
Medicaid physician payment reform: using the Medicare Fee Schedule for Medicaid payments.
OBJECTIVES: The purpose of this article is to provide estimates of the costs of basing Medicaid physician payment levels on the new resource-based Medicare Fee Schedule. Two possible policy options are considered: setting all Medicaid physician fees at the Medicare Fee Schedule level and setting only office visit fees at the new Medicare levels. METHODS: Data on Medicaid physician fees, use patterns, and the Medicare Fee Schedule are used to develop state-level estimates of expenditure changes under each option. RESULTS: Setting Medicaid rates at the Medicare Fee Schedule level could increase expenditures by $3.2 to $4.1 billion nationally; the other option would result in substantially lower increases in expenditures. Because of the current variations in Medicaid physician fees and in the breadth of eligibility across states, the cost of adopting the Medicare Fee Schedule varies considerably among states. CONCLUSIONS: Adopting the new Medicare Fee Schedule for Medicaid payments, proposed by policy-makers as a way to increase access to appropriate medical care, could double physician expenditures in some states. Adoption of more limited versions of the fee schedule might achieve some access gains at lower costs.
The demise of value: reasons against Medicare E&M guidelines.
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