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At least 253 records · Page 14Linked to original sources
PubMed1999

[Social medicine aspects of growth hormone treatment of children].

A growing number of innovative, high-cost drugs call for assessment from social medicine. Synthetic human growth hormone (somatropin, STH) is a prominent example. The use of STH in children greatly increased over the last few years. Treatment extends over years and cost may add up to 30,000 to 70,000 DM/year. STH is licensed for treatment of insufficient secretion of growth hormone, in girls with Ullrich Turner Syndrome and in prepubertal children with chronic renal failure. Off-label use of STH is widespread. The following questions arise: Is STH treatment medically necessary? Must social security (health insurance) carriers pay for STH treatment? Which methods are appropriate to analyse growth and to ascertain growth hormone deficiency? The stated target of STH treatment is a relevant increase of body height. Is this target achieved in the various indications? Special problems arise where psychosocial considerations are put forward.

Adolescent↗
PubMed1999

Problems of transition from tax-based system of health care finance to mandatory health insurance model in Russia.

This article examines three problems burdening the Russian system of health care finance in transition period: (a) unrealistic government promise to cover health care coverage too wide to be achieved with available resources; (b) inefficient management of health care delivery systems; and (c) lack in evidence of actual positive changes effected by the new players: mandatory health insurance carriers and funds. Radical reshaping of the health benefits promised by the government and introduction of patient co-payments are considered as a way to normalize public health sector finance and operations. Two alternative approaches to the reform of the existing eclectic system of health care management are available. Institutional preconditions for operational effectiveness of third-party purchasers of health services in public-financed health sector are defined.

Delivery of Health Care↗
PubMed1980

Food and Drug Administration, HHS.--General; dental radiographs. Final recommendations.

The agency is issuing a recommendation that insurance carriers and other remote parties refrain from requiring administrative dental x-ray examinations. Administrative dental x-ray examinations are those required by a remote third party (other than a patient's dentist or physician) for reasons not related to the patient's immediate dental needs. These dental x-ray examinations may result in unnecessary radiation exposure to the patient. This recommendation is a part of the agency's effort to minimize unnecessary exposure of the public to ionizing radiation.

Humans↗
PubMed1977

The future of Blue Cross.

This paper analyzes the reasons for the rise and decline of Blue Cross, a unique American institution. Its inability to respond to the crisis in today's health system is described as nothing more than the failure of the ailing American health system to cure itself. The early rise of Blue Cross is attributed to its success in addressing pressing social needs: helping patients afford the costs of hospitalization and helping hospitals meet expenses. Its later decline is traced to several factors: the striking increase in the costs of health care; the rise of the state insurance commissioner; the anticipated passage of national health insurance; and the increased competition from commerical insurance carriers, specialty health care data and management firms and state governments. In concluding, the question is raised whether society should invest further in the future Blue Cross, a social institution which may have irrevocably lost the confidence of the general public, government and the health provider community. Four possible futures for Blue Cross are set forth: the outright collapse of several plans, a "Lockheed-type" bailout, a "Naderist" organization strongly allied with consumers, and a quasi-governmental agency.

Blue Cross Blue Shield Insurance Plans↗
PubMed1976

Economic analysis of an automated billing system for physicians' services.

An on-line Medicaid billing system for physicians' services was implemented and tested during a two and one-half year period in 100 offices throughout the State of +0.50,Alabama. Participating physicians represented 17% of all physicians in the state. The monthly volume of Medicaid claims entered through the system represented more than 50% of the statewide load processed by the Medicaid carrier. Users entered claims data on standard Touch Tone telephones equipped with Carddialers, and received instructions and data confirmation from the central computer facility via voice answer-back. Input time for the average claim billing for two separate services was less than one and one-half minutes and resulted in a reduction of clerical labor required for manual input by at least 50%. After a fee-for-service was inaugurated, the system workload remained at 86% of its load level before fee for service. Those physicians willing to pay for the billing service were high-volume users who had come to depend on the system and who appreciated the economics that the system had achieved for them in their office billing practices. An average claim consisting of two items of service could be billed at a cost of $0.50,, exclusive of user terminal rental ($6 per month per office) and the cost of data entry personnel (between $0.05 and $0.10 + 0.05 and $.10 per claim). Various algorithms have been offered for use in estimating an annual budget for an on-line billing system given alternative system configurations, methods of financing, annual volume of units of service, and the geographical nature of the population to be served. The tasks of preparing, processing, and storing insurance claims information have placed a costly and time-consuming burden on both providers of medical services and fiscal intermediaries. The unfortunate result is that the cost of submitting an insurance claim for professional medical services is a disproportionate fraction of the amount paid for providing the service. For general practitioners, who provide the largest number of individual services, this share may be more than one-fourth of the payment for most common services. Similarly, for the Medicaid or Medicare intermediary or for the insurance carrier, the cost of preparing and recording data from source documents is a large part of total processing costs. The objective of the On-Line Medicaid Billing System project was to demonstrate that it is possible to reduce the costs of submitting claims from the physician's office as well as to reduce the costs of data preparation in the carrier's system. This publication focuses on an economic analysis of cost effectiveness. Readers interested in system design, development, and on-line operation will find detailed descriptions in previously published reports.

Accounting↗
PubMed1992

Expediting prior approval and containing third-party costs for dental care.

Dental insurance carriers frequently require referral of radiographs for determination of prior approval. Radiographs are also often used for obtaining expert opinions before finalizing diagnoses and establishing treatment plans. Traditionally, such referrals have been carried out using the original or duplicate films transmitted through the postal system. Studies concerning alternative communication media for data transmission are presented, namely, the use of switched-digital telephone lines and of electronic mail networks.

Computer Communication Networks↗
PubMed1957

Work injury: a second look at the doctor's first report.

Injured employees require medical care and, if disabled, compensation payments for subsistence. The law requires that the employer or insurance carrier supply these benefits promptly. In the absence of prompt and adequate information from the attending physician, these benefits are withheld. The necessary information required to process employee's claim is that called for on the standard accident report form, commonly called the "pink slip." Not to supply this minimum information may constitute a hardship on the employee. By supplying more elaborate information than that called for, the physician may be increasing his load of "paper work" immeasurably.

Persons with Disabilities↗
PubMed2004

Effect of loss control service on reported injury incidence.

INTRODUCTION: A retrospective analysis evaluated the effectiveness of an insurance carrier's flexible loss control service strategy in reducing workers' compensation policyholders' reported injury and illness claims. OBJECTIVES: To assess the effects of a loss control service strategy on workers' compensation claim frequency rates, on medical-only claim rates, on severity-claim rates, and on claim cost among a group of California employers. METHODS: Eighty-two small- and medium-sized companies with workers' compensation policies expiring in 1999 were randomly selected from a population of policyholders assigned to loss control consultants for two or more years. Claim performance data were obtained for each company's first expired in-force policy year and its 1999 expired policy year. The retrospective design was combined with a control component based on a randomly selected comparison group of 45 companies whose first policy year with the insurer expired in 1999 and who received safety services from the loss control staff. RESULTS: The flexible loss control consultation service strategy was associated with lower average claim rates and costs. Companies assigned to a loss control consultant for two or more years (the "outcome group") had an average claim rate of 1.24 per $10,000 premium, compared with a rate of 1.62 in the "initial group" and a rate of 1.60 in the "comparison group." The average severity-claim rate of the outcome group was 0.32, compared with the initial-year and comparison-group means of 0.48 and 0.46, respectively. The average medical-only claim rate was 0.92, compared with the initial- and comparison-group means of 1.14 and 1.14. The outcome group's average loss ratio was over 10% lower than that of the initial and comparison groups. Statistical analysis indicated that differences among the groups' claim rates and severity-claim rates were [F=(2,206) 4.938, P=0.008] and [F=(2,206) 8.208, P<0.001], respectively. CONCLUSIONS: A loss control service strategy that provides service flexibility and develops partnership between employer and consultant can help reduce the frequency and severity of workers' compensation claims. Barriers to consultation service flexibility, both internal and external, should be identified and removed to enhance service efficacy.

Accidents, Occupational↗
PubMedDate not supplied

Statistical models of outcome in malpractice lawsuits involving death or neurologically impaired infants.

The objective was to determine whether factors could be identified in medical and legal records that are associated with the successful defense of obstetrical malpractice cases involving the death or neurological impairment of infants. Obstetrical claims (169) closed by PROMUTUAL between January 1, 1990, and December 31, 1994, were retrospectively abstracted and analyzed to identify associations between medical and legal factors, and the medicolegal outcome. Multivariable analysis identifies that the use of pitocin, diagnosis of asphyxia, a delay in delivery, and the use of multiple defense expert witnesses decreased the chances of a successful defense. Two statistical models explaining indemnity payment were developed. The first, based on medical outcome, showed an increased indemnity payment when a case involved major neurological deficits, diagnosis of asphyxia, newborn seizures, later year of delivery, and participation of a particular defense firm. Perinatal or childhood death and the use of pitocin were indicators of a decrease in payment. The second model was based on long-term care requirements. In this model, indicators of increased indemnity payment were: nonreassuring intrapartum fetal heart rate tracing, later year of delivery, intensity of long-term care required, and participation of a particular defense law firm. Perinatal or childhood death, the use of pitocin, and settlement date increasingly removed from the occurrence date were the determinants of decreased payments in this model. Finally, the presence of major neurological deficits, the prolongation of a case, and the involvement of multiple law firms and defense witnesses increased the expense charged to and paid by the insurance company. Using the medical, legal, and financial data relevant to 169 obstetrical cases closed by one malpractice insurance carrier between 1990 and 1994, statistical models with potential predictive values for future malpractice claims involving neurologically impaired infants were constructed. These models may help determine in advance the chance a future case has for successful defense and the likely amount of expense and indemnity dollars that will be paid out to settle and defend it.

Adolescent↗
PubMed1987

Medical imaging's dynamic future.

Radiology's survival as a specialty is threatened because of the significant changes that have occurred in the healthcare environment over the past five years. Changes in reimbursement, expectations by referring physicians, and demands by insurance carriers and the employees they represent have all had an impact on the volume of patients admitted to hospitals and being referred to various physicians. This has directly impacted radiology practice in terms of the types and numbers of procedures performed as well as through competition which has developed for providing traditional radiology services. It is clear that changes will continue to affect radiology practice in terms of reimbursement and specialty needs far into the future. Various entities that are involved in providing services to hospitals as well as to radiology practices will continue to have an impact on what radiologists do and how they do it. It is important that radiologists be willing to restructure their own individual radiology practices and modify their educational background and experience so that they can provide the best possible services to the referring physicians and the best support to the various insurance programs that are provided to them. The greater the extent to which radiologists are willing to improve the quality as well as effectiveness of their support services, the greater the likelihood that their practices will be successful into the future.

Diagnostic Errors↗
PubMed2004

E-mail consultation: clinical, financial, legal, and ethical implications.

BACKGROUND: Communication via e-mail has become widespread. Nearly every practicing neurosurgeon is confronted with numerous unsolicited e-mail requests for medical advice, guidance, or information. Neurosurgeons need to be aware of the clinical, financial, legal, and ethical implications of providing medical consultation via e-mail. METHODS: A literature review of the penetration of e-mail consultation in medical practice was performed. The data on the potential for reimbursement for provision of these services is presented. Precedents for legal liability are discussed, and issues of compliance with HIPAA regulations are reviewed. RESULTS: Communication between patients and physicians via e-mail is increasing in prevalence, and a substantial number of physicians are providing medical information via e-mail consultation. Billing for online consultation has been approved by the American Medical Association, and several medical insurance carriers are evaluating the economic consequences of reimbursement for e-mail consultation. E-mail consultation raises potential medico-legal concerns, including establishment of the physician-patient relationship, malpractice liability, and HIPAA compliance. CONCLUSIONS: The increasing prevalence of e-mail consultation raises new concerns for neurosurgeons. Some of these concerns have yet to be addressed by regulatory commissions or in the courts. If used appropriately, e-mail communication can facilitate physician-patient interactions, improve access to care, save time for each interaction, and possibly reduce costs of care.

Electronic Mail↗
PubMed1994

Physical therapy episodes of care for patients with low back pain.

BACKGROUND AND PURPOSE: Although individuals with low back pain frequently receive treatment from a physical therapist, few published studies exist that describe who sees a physical therapist for their low back pain nor is much known about physical therapy episodes of care for this condition. Secondary analysis of data from the American Physical Therapy Association's Survey of Physical Therapy Outpatient Practice provides new descriptive data on services provided to a national, representative sample of patients discharged from hospital-based and private outpatient practices. In addition, specific hypotheses were tested on clinical and background factors believed to influence low back pain episodes of care. SUBJECTS: Patients with low back pain represented over 25% of all outpatient discharges from physical therapy practices. METHODS: A mail survey was conducted with representatives of a national probability sample of facilities that provided outpatient physical therapy services. Data were provided on each facility and on a discharge sample of patients treated at each facility. RESULTS: On average, episodes of care extended over 5 weeks and consisted of 11 therapy visits, for an average charge of $766.70. Duration and charge for low back episodes of care did not differ, on average, in private versus hospital-based practices. Certain aspects of care, however, did vary across regions of the country. Episodes of care charged to workers' compensation were costlier than those charged to other insurance carriers, and whites were charged less, on average, than nonwhites. Duration of back symptoms was related to intensity, duration, and charges incurred for the episode of care. CONCLUSION AND DISCUSSION: Further research is needed to understand the reasons for the relationships observed in this study, as well as studies that relate care provided by physical therapists to specific patient outcomes. Further research is also needed to compare outcomes achieved across different health professions.

Adult↗
PubMed1997

The impact of policy standardization on the Medigap market.

This study examines the impact of policy standardization on the market for Medicare supplemental, or "Medigap," policies. Prior to 1992, insurance carriers could sell any benefits they chose, so long as minimum benefit requirements were met. In July 1992, federal legislation was implemented that required all new Medigap policies to conform exactly to one of 10 standardized sets of benefits. Using pre- and post-standardized policy information from six states, this study analyzes the impact of this legislation. Overall, standardization has affected the market positively, and as a result, consumers are better able to make informed choices about the benefits they are purchasing.

Community Participation↗
PubMed2004

The "new" medical malpractice crisis--part 1.

It is important to put the current medical malpractice crisis into the historical context of the past several decades. Doing so provides an important perspective from which to understand the current iteration. One may reasonably conclude that the present medical malpractice situation is only the latest outbreak of a continuing, chronic condition, rather than a distinct, unusual event. In this regard, it is analogous to a chronic disease that occasionally flares up. Chronicity suggests the presence of major underlying problems, which may be linked to insurance carriers' business cycles as much as reflecting increases in either medical malpractice or the numbers and value of claims. It is useful to bear in mind that the fact of a claim may or may not indicate actual medical malpractice, and increased claims could well correlate more closely with patients' disgruntlement with the medical delivery system, access to it, and the way they were treated by staff than with significant injuries for which compensation should be paid. Regulatory and public policy efforts to date have only affected the problem of medical malpractice at the margin. Apparently, the core of the problem has not been addressed; in fact, it seems as yet to be unidentified. Solutions that focus on the economic dimensions only address the symptoms-claims for medical malpractice-and apparently have done nothing to correct the root cause(s). Part 2 of this two-part series considers and analyzes the current medical malpractice insurance crisis. Its evolution and analysis of specific aspects may provide guidance in understanding how to predict its future course. More important, the analysis will suggest guidance as to how organizations may reduce the potential for the problem and protect themselves from the negative aspects, should it occur.

Humans↗
PubMed1990

Trilogy of the "Triad of O'Donoghue" in the knee and its analogy to the TMJ derangement.

An attempt has been made to describe the similarities between the pathological injury "Triad of O'Donoghue" in the knee and its analogous equivalent in the internal derangements of the temporomandibular joint (internal derangements). Because of the similarities between these internal derangements and the treatment they require, TM joint internal derangements should be reimbursed as a medical problem by insurance carriers as internal derangements in the knee are reimbursed. A description of the anatomical, physiological, and arthro-kinomatics of these two synovial joints has been done to further point out that they both operate by the same physiological principles, and therefore should be treated as similar dysfunctions. Treatment should be rendered to the TM joint, as in the knee, from an orthopedic viewpoint. This requires that treatment to the TM joint include a cooperative rehabilitative team approach. This team approach encompasses medical and dental cooperative care to stabilize the joint and secondarily control joint related soft tissue compensation and pain.

Abstracting and Indexing↗
PubMed1983

Patient education in the hospital health-care setting.

The implementation of patient education within the hospital setting can be justified for a variety of reasons. The rationale for implementing patient education can be justified in terms of escalating emphasis on consumerism and informed participation on the part of the health-care recipient, the support of federal legislation, the support of hospital regulatory bodies, the support of third-party insurance carriers and private foundations, increased cooperation and compliance on the part of the patient, reduced stress levels for the hospitalized patient, and the improvement of staff-patient relationships. All of these serve as a database that justifies the integration of patient education within hospital care services. Patient education is the responsibility of the existing health-care system. In many instances, patient education is still not being approached in a serious manner. Therefore this paper attempts to provide a number of reasons health-care professionals functioning within the hospital setting should implement this process.

Data Collection↗
PubMedDate not supplied

Can we monitor socioeconomic inequalities in health? A survey of U.S. health departments' data collection and reporting practices.

OBJECTIVE: To evaluate the potential for and obstacles to routine monitoring of socioeconomic inequalities in health using U.S. vital statistics and disease registry data, the authors surveyed current data collection and reporting practices for specific socioeconomic variables. METHODS: In 1996 the authors mailed a self-administered survey to all of the 55 health department vital statistics offices reporting data to the National Center for Health Statistics (NCHS) to determine what kinds of socioeconomic data they collected on birth and death certificates and in cancer, AIDS, and tuberculosis (TB) registries and what kinds of socioeconomic data were routinely reported in health department publications. RESULTS: Health departments routinely obtained data on occupation on death certificates and in most cancer registries. They collected data on educational level for both birth and death certificates. None of the databases collected information on income, and few obtained data on employment status, health insurance carrier, or receipt of public assistance. When socioeconomic data were collected, they were usually not included in published reports (except for mothers educational level in birth certificate data). Obstacles cited to collecting and reporting socioeconomic data included lack of resources and concerns about the confidentiality and accuracy of data. All databases, however, included residential addresses, suggesting records could be geocoded and linked to Census-based socioeconomic data. CONCLUSIONS: U.S. state and Federal vital statistics and disease registries should routinely collect and publish socioeconomic data to improve efforts to monitor trends in and reduce social inequalities in health.

Birth Certificates↗
PubMedDate not supplied

Capitation reimbursement: a progress report.

A capitation reimbursement experiment for inpatient hospital services was initiated in North Dakota and Massachusetts four years ago. The per capita fixed payment program provided participating hospitals with incentives to economize that are similar to those which physicians have in health maintenance organizations. The relationship between the insurance carrier (Blue Cross) and participating accounts (business firms) and subscribers did not change. At Harrington Memorial Hospital actions were taken to increase efficiency and effectiveness, expand market share, and address medical practice issues. The favorable variance in the total average charge per case between the treatment of patients at Harrington (home-hospital) versus other institutions (host-hospitals) was increased. The less expensive treatment at Harrington helped to produce a capitation surplus of $143,123 for home hospital claims. Final data for host hospital claims for FY 1982-1984 is not currently available. The most recent estimate indicates that Harrington will achieve an overall financial surplus of $312,406. At final settlement, the hospital will retain 75% of the surplus and Blue Cross will receive 25%.

Blue Cross Blue Shield Insurance Plans↗