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At least 235 records · Page 13Linked to original sources
PubMed2003

Major lower extremity amputation in an academic vascular center.

Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.

Academic Medical Centers↗
PubMed1977

Obtaining state legislation for insurance coverage of day hospitalization.

Whether a patient receives treatment in a 24-hour inpatient setting or a less restrictive day hospital program often depends strongly on what kinds of care the patient's health insurance policy covers. In 1974 advocates of partial hospitalization programs in Maryland began working for a state law requiring third-party payers to provide day hospital benefits to all policyholders. After realizing that the bill as drafted would not pass the legislature, its advocates negotiated with insurance carriers, legislators, and others. The bill was rewritten so that day hospital coverage must be offered as an option in group policies only, and at an adjusted premium if necessary. It was enacted into law in 1976 and became effective in January 1977.

Day Care, Medical↗
PubMedDate not supplied

Medical care utilization and the transcendental meditation program.

This field study compared 5 years of medical insurance utilization statistics of approximately 2000 regular participants in the Transcendental Meditation (TM) program with a normative data base of approximately 600,000 members of the same insurance carrier. The benefits, deductible, coinsurance terms, and distribution by gender of the TM group were very similar to the norm, yet the TM group had lower medical utilization rates in all categories. Inpatient days per 1000 by age category were 50.2% fewer than the norm for children (0-18), 50.1% fewer for young adults (19-39), and 69.4% fewer for older adults (40+). Outpatient visits per 1000 for the same age categories were, respectively, 46.8%, 54.7%, and 73.7% fewer. When compared with five other health insurance groups of similar size and professional membership, the TM group had 53.3% fewer inpatient admissions per 1000 and 44.4% fewer outpatient visits per 1000. Admissions per 1000 were lower for the TM group than the norm for all of 17 major medical treatment categories, including -55.4% for benign and malignant tumors -87.3% for heart disease, -30.4% for all infectious diseases, -30.6% for all mental disorders, and -87.3% for diseases of the nervous system. However, the TM group's admission rates for childbirth were similar to the norm. The issue of self-selection is addressed in terms of previous medical research in this area.

Adolescent↗
PubMed1995

Genetic testing: employability, insurability, and health reform.

Presently, 85%-90% of individuals with private health insurance are covered under group health insurance, with most covered through employment. Under virtually any system of health care reform likely to be enacted in the near future, employers will continue to play a major role in the funding of private health care. As costs of health care are increasing dramatically, employers and insurance carriers are examining alternatives for controlling health care expenditures. Not all consumers of health care are equal in their rates of consumption. Tremendous savings could be realized by parties responsible for paying for health care if the most expensive (or potentially most expensive) health care users could be identified and their costs shifted to another payer. Genetic testing could play a major role in predictive health screening to identify individuals with the potential for developing cancer. This prospect raises three major problems regarding employability and insurability. First, individuals could be subject to discrimination in employment, with the responsibility for their health coverage shifted to the public sector. Second, privacy and confidentiality could be compromised through the compilation, storage, and release of non-job-related, sensitive medical information. Third, the fear of employment discrimination through employer access to medical records generated in the clinical setting might discourage at-risk individuals from undergoing medically indicated genetic testing. This report reviews these issues and emphasizes that these concerns must be addressed in the context of health care reform as well as through the interpretation of existing legal proscriptions on employment discrimination.

Cost Control↗
PubMed1992

Case vignette: the vicissitudes of managed care.

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?

Delivery of Health Care↗
PubMed2001

Access to medical care for occupational disorders: difficulties and disparities.

Despite state laws guaranteeing full insurance coverage for work-related disorders, many injured workers have difficulty obtaining access to appropriate medical care. Barriers to access arise because: patients are unable to prove that their conditions are caused occupationally; they are discouraged by employers from reporting occupational injuries; workers' compensation insurance carriers aggressively contest claims; and other reasons. Evidence suggests that minority subpopulations of workers are most affected. Overcoming these barriers will require a multifaceted approach involving regulatory oversight, participation of workers in the design of health plans and the selection of providers, and specific measures to detect and prohibit discriminatory care.

Health Services Accessibility↗
PubMed1983

Recommendations on administratively required dental radiographs.

The FDA recommendation on administratively required dental X-ray examinations states a principle that has been frequently endorsed by the American Dental Association. This recommendation, developed through a formal review process, reflects the views of dentists, educators, insurance carriers, professional societies, and other interested health professionals. Simply stated, it urges dentists to perform only X-ray examinations that are necessary for the patient's immediate dental needs. Dentists and others are urged to refer to this recommendation when presented with requests for radiographs considered unnecessary for patient care.

Humans↗
PubMed2002

Enforcing prompt-payment regulations: the Texas approach.

To ensure that insurance carriers pay providers in a timely manner, Texas has adopted strict payment regulations. Enforcement of the regulations has led to restitution payments for many providers. However, issues such as clean claims, underpayment, discrepancies in payment dates, and self-funded claims continue to present challenges.

Efficiency, Organizational↗
PubMed1995

Fee-for-service versus capitation-based reimbursement: how the payment method affects utilization of echocardiographic services by referring physicians.

Historically, health insurance carriers (HIC) have reimbursed physicians on a fee-for-service basis for echocardiographic studies. With the emergence of managed care, the HIC now may have the option of paying on a capitation basis. To determine whether the method of reimbursement had any bearing on the types of patients referred for echocardiographic services, we conducted a two-phase (retrospective) study. In Phase One, we assessed two groups of ambulatory patients with regard to patient characteristics, medical reason for referral, and echocardiographic results. Group A (4,066 patients) had insurance plans that stipulated reimbursement for echocardiographic services as part of capitation for cardiology services. Group B (3,061 patients) had plans that reimbursed for echocardiographic services on a fee-for-service basis. In Phase Two, we assessed a total of 5,947 patients (3,833 from Group A and 2,114 from Group B) over a period of 40 months to determine the frequency of referral for a second echocardiogram within 2 years of a normal one and the repeat normalcy rate. The results showed that the capitation reimbursement group included younger, predominantly female patients who were referred more often for a more benign reason and who more frequently were diagnosed echocardiographically with less severe disease, higher rates of normalcy, and repeat normalcy. These findings suggest that in our geographic area the capitation method of reimbursement permitted more liberal utilization of echocardiographic services. In this era of cost awareness, the study suggests the need for better screening of patients referred for echocardiographic services.

Capitation Fee↗
PubMed2006

Legal issues impacting women's access to care in the United States-the malpractice insurance crisis.

Professional liability insurance costs have increased rapidly in the last 10 years in the United States, while availability of companies offering professional liability insurance has decreased. The result is that ob-gyn physicians are changing their practice patterns. Many are no longer performing difficult or complex surgical procedures while others have stopped caring for obstetrical patients. Some physicians are retiring early or moving to other localities where there are less liability concerns. These changes all impact on the availability of health care for women. In addition, these problems have become a concern of medical students, and this is reducing the numbers considering a career in ob-gyn. Even where ob-gyns are available, hospitals and insurance carriers are limiting their ability to practice the wide range of procedures for which they were trained. Although legislative efforts to correct the problems are proposed, very few have been enacted. The end result is that women's health care has been threatened and will continue to face shortages and restrictions.

Female↗
PubMed1989

Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring.

Among 1,001,000 ASA Physical Status I and II patients (a subset of the 1,329,000 anesthetics administered from 1976 through mid-1988 in the nine component hospitals of the Harvard Department of Anaesthesia), there were 11 major intraoperative accidents solely attributable to anesthesia (five deaths, four cases of permanent CNS damage, and two cardiac arrests with eventual recovery) among the 70 cases reported to the insurance carrier. Review of these accidents revealed that unrecognized hypoventilation was the most common cause (seven cases). These seven accidents and one other due to discontinuation of inspired oxygen in all likelihood would have been prevented by appropriate response to earlier warnings generated by the "safety monitoring" principles mandated by the Harvard minimal monitoring standards. Analysis suggests capnography (although not mandated) would be the best monitor of ventilation. An important associated issue was the apparent inadequacy of supervision of residents and C.R.N.A.s. The eight preventable accidents represent 88% of the projected insurance payout. Only one accident occurred after the 1985 adoption of the standards (in the month following their implementation). From that time through mid-1988, there have been 319,000 anesthetics without a major preventable intraoperative injury. Although not statistically significant, the accident rate in the target population of healthy people is reduced more than threefold. This and the case analyses support the contention that nearly all the inevitable mishaps (technical or from errors in judgement) that occur during anesthesia can be identified through safety monitoring early enough to prevent most major patient injuries. This improved clinical outcome should lessen the medical-legal and malpractice insurance burdens of anesthesiologists.

Accident Prevention↗
PubMed1989

Implementing medical staff malpractice insurance requirements.

Hospitals have recently begun to explore and adopt medical staff membership criteria that go beyond simply determining a practitioner's ability to practice medicine. Medical competence and expertise will always play a central role in medical staff membership decisions. However, the increasing competition among hospitals for patients with the attendant pressure to contain health care costs has caused hospitals to consider business factors in the composition of their medical staffs. To ensure their own survival, hospitals need to be efficient and sensitive to the financial dynamics of the industry as they determine the composition of their medical staffs. One response to the new business reality of health care by hospitals is the adoption of minimum medical malpractice insurance requirements for medical staff members. In large part, hospitals have adopted these requirements at the insistence of certain insurance carriers. Although there has not been much litigation over this issue, a handful of cases has held that such requirements are reasonable because they help to protect the hospital's assets and to ensure that patients have a source of funds for recovering damages caused by malpractice. These courts have recognized that it is a board's duty to protect the financial well-being of the hospital and that such requirements help to satisfy this duty. This article will describe the case law that upholds such requirements, analyze the problem regarding practitioners who cannot comply with a hospital's insurance requirements because such coverage is not available to them, and discuss the problems and possible resolutions regarding adoption and implementation of such a requirement.

Insurance, Liability↗
PubMed1994

Barriers to clinical trials. Part I: Reimbursement problems.

Most of the major clinical advancement in cancer treatment has been provided by cancer clinical trials. Approximately 60% of clinical trials are conducted in the community treatment setting and approximately 40% in academic and cancer centers. The cost of these trials are borne by a combination of third-party reimbursement for the cancer care and institution and research study support for the specific cost of the research trial. With the increasing emphasis on cost control, managed cancer care, and health care reform, there is evidence of increased resistance and even denial of third-party insurance carriers for the usual cancer care done in association with cancer clinical trials. If this issue is not specifically addressed in today's managed care environment or in proposed health care reform, there will be a severe barrier to future cancer clinical research and an associated decrease in the identification and evaluation of new and better cancer treatment.

Clinical Trials as Topic↗
PubMed2003

Health services research.

The major barriers to the collection of primary population-based dental services data are: (1) Dentists do not use standard record systems; (2) few dentists use electronic records; and (3) it is costly to abstract paper dental records. The value of secondary data from paid insurance claims is limited, because dentists code only services delivered and not diagnoses, and it is difficult to obtain and merge claims from multiple insurance carriers. In a national demonstration project on the impact of community-based dental education programs on the care provided to underserved populations, we have developed a simplified dental visit encounter system. Senior students and residents from 15 dental schools (approximately 200 to 300 community delivery sites) will use computers or scannable paper forms to collect basic patient demographic and service data on several hundred thousand patient visits. Within the next 10 years, more dentists will use electronic records. To be of value to researchers, these data need to be collected according to a standardized record format and to be available regionally from public or private insurers.

Communication Barriers↗
PubMed2001

The WOC nurse in home care.

Visiting nurses have provided care to people in their homes for more than a century. Although their role has changed dramatically during the past 100 years, home care nurses remain committed to the key principle of promoting health and welfare while sustaining the values of patient and the home. Patients referred for home care today have increasingly complex and extensive needs. Financial constraints imposed by the government and insurance carriers have accelerated the need for efficiency and excellence in communication, coordination of care, and management of these patients. The WOC/ET nurse practicing in home care can play an invaluable role in promoting positive patient outcomes, developing patient care policies and treatment plans, and establishing standards of care for patients receiving care for chronic wounds, ostomies, or incontinence.

Community Health Nursing↗
PubMed1994

What is the cost of compliance?

The Association was long aware that compliance with infection control procedures and regulations was having a significant effect on dental practices. For that reason, findings from the current survey were not surprising. There was, however, an incontestable need to collect precise data on the impact infection control requirements were having on dental practices. This was particularly crucial given the marked differences between OSHA's own compliance cost estimates and the experiences of dental insurance carriers and dental practices. This article provides a brief overview of a very thorough and comprehensive survey. A more complete description of the findings will be presented to the 1994 ADA House of Delegates through council reports. Results also will be disseminated to ADA agencies for use in appropriate Association programs and activities.

Blood-Borne Pathogens↗
PubMed1957

Disability; is it permanent?

Too often cases of industrial injuries are submitted for permanent disability rating before maximum recovery is attained and the condition is permanent and stationary. This is frequently a situation that is detrimental to the injured working man, since his physical disability might be further reduced by additional treatment, and his future earning power and economic status thus be improved. Also it may be detrimental to the insurance carrier and/or employer, since in some instances it results in increased permanent disability award payments for portions of the condition which are not truly permanent. Inadequate medical reports also are a frequent cause of unfair awards. The necessary factors used to arrive at proper conclusions, the errors that have been observed and the importance of this problem are discussed.

Persons with Disabilities↗
PubMed1994

Strategies for increasing third-party reimbursement for nutrition counseling.

OBJECTIVE AND SETTING: The purpose of this two-phase project was to determine whether specific interventions would affect third-party reimbursement for outpatient nutrition services at the Nutrition Clinic of the Los Robles Regional Medical Center. DESIGN, SUBJECTS, AND INTERVENTION: In phase 1, the baseline reimbursement rate was determined by a questionnaire mailed to 191 clients seen in the clinic from January 1 to September 30, 1989. The survey was completed by 115 clients (60%). In phase 2, two strategies were used to increase reimbursement: instructing clients about how to file claims and providing clients with form letters of medical necessity to submit with their claims. The strategies were applied to 76 new clients from March 15 to July 31, 1991. Five weeks later, 67 of the 76 clients (88%) were interviewed by telephone. OUTCOME MEASURES: The primary outcome measures were submission rates and reimbursement rates. RESULTS: The results showed that in phase 1 (before intervention), 75 of the 115 clients surveyed (65%) submitted claims to their insurance carriers, and 12 of the 74 clients (15%) whose claims were acted on received reimbursement. In phase 2, 47 of the 67 clients (70%) submitted claims, and 15 of the 36 clients (42%) whose claims were acted on received reimbursement. Of the 20 clients who did not submit claims, 8 did not apply because of time constraints, and 5 did not apply because of low expectations of reimbursement. APPLICATIONS/CONCLUSIONS: Form letters of medical necessity increased the reimbursement rate, but client instruction did not increase the submission rate. Most of the clients who did not submit a claim said they did not have time to do so. Therefore, the Nutrition Clinic is attempting to submit insurance forms for the clients after clients have paid for the consultation. Other providers of outpatient nutrition counseling who follow this strategy may increase the reimbursement rate.

Adult↗