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PubMed1995

Controlling outpatient medical equipment costs through utilization management.

Utilization management programs have been widely used to control hospital inpatient costs, but little is known about their potential to control outpatient costs. Claims data covering a 21-month period beginning in January, 1990 were analyzed to evaluate the effects of a utilization management program established by an insurance carrier to contain costs for durable medical equipment. Four items were targeted for review: seat lifts, transcutaneous electrical nerve stimulator (TENS) 2 and TENS 4 units, and power-operated vehicles. The program was associated with significant reductions (P < 0.05) in order requests, supplier charges, and claims payments for three of the four targeted items. Under the program, the rate of denials increased significantly (P < 0.05) for two of the targeted items. Most of the program's cost savings accrued from a "sentinel" or volume effect, not from an increase in denials. These findings provide further evidence of the cost containment potential of utilization management. Focused utilization management programs that target provider groups, patient populations, or service sectors experiencing high volume have the greatest chance of achieving cost savings.

Ambulatory Care↗
PubMed1997

The German health-care system.

The German health-care system is characterized by a statutory health insurance based on the principle of social solidarity. Nonprofit sickness funds and regional associations of physicians are the central components of the German system. The historical development of the system for more than 100 years has been characterized by negotiations, rather than confrontation, among physicians, patients, and insurance carriers. With the increasing sophistication of modern medicine, medical expenditure is rising, and great demands are facing the health-care systems of the industrialized world. The hope is that the German system will be able to preserve the principle of solidarity and remain a one-tier health-care system rather than allow health care to be viewed as essentially a private consumption good, in which case availability and quality are allowed to vary with family income. As a means to achieve this goal, the autonomy of the sickness funds and regional associations of physicians will be increased substantially, and the governmental authority will be decreased. Strengthening of autonomy must be accompanied by incentives for self-responsibility and self-participation of Germany's citizens.

Delivery of Health Care↗
PubMed1988

Capitation and fee-for-service dental benefit plans: economic incentives, utilization, and service-mix.

Insurance carriers, corporations, and labor groups are actively developing and marketing dental capitation benefit plans. Incentives to both dentists and patients in these plans differ from those in the traditional fee-for-service system used with conventional benefit plans. This paper describes the likely effects of these incentive differences on utilization and service-mix patterns in both systems. Data for a large (approximately 10,000), homogenous group of subscribers are presented and discussed. Faced with a dual option, at no cost to the employee, 60% of the subscribers chose the fee-for-service plan, and 40% chose the capitation plan. Observed differences in the utilization and mix of services between the two plans cannot be explained solely in terms of dentists' responses. Employee response to altered economic incentives appears to be strong.

Capitation Fee↗
PubMed1997

The search for the elusive electronic medical record system--medical liability, the missing factor.

Over the past few years, the traditional paper-based medical record system has come under close scrutiny by every participant in the healthcare industry. Some groups, especially federal agencies such as Medicare and Medicaid, HMOs, and other third party payors, have begun to demand changes in medical record documentation, and have become very assertive as to what goals and objectives will be met. In contrast, the medical liability insurance industry has remained almost invisible during this period of transition. At a recent electronic medical records (EMR) conference participants attending a software development workshop were asked if they had their systems reviewed from a medicolegal standpoint by a malpractice insurance carrier. In response to this inquiry, not one software vendor raised their hand to indicate this had been accomplished, or was even contemplated. In the author's opinion, the key missing factor in the current quest for a paperless medical office system rests in the domain of those who represent the medical liability industry. All of these gate-keepers of medical loss and risk prevention will eventually be called upon, either by choice or necessity, to validate every working EMR system that is used in medical practices in the future. This article will explore the best information published from this currently silent sector of the industry, and proposes an active involvement by the medical liability industry in the current EMR design and development processes taking place. In addition, there are 10 minimum EMR design criteria contained in this article that are recommended for implementation based upon 16 years of medical malpractice experience and loss prevention input.

Humans↗
PubMed1999

Clinical practices in the management of new-onset, uncomplicated, low back workers' compensation disability claims.

Recent consensus guidelines delineate what appears to be the most successful and cost-effective management of low back pain (LBP), and some recent studies have suggested that better outcomes occur with the least aggressive forms of medical intervention. The purpose of this study was to describe how practitioners manage new-onset, uncomplicated low back workers' compensation (WC) disability cases. A sample of cases was randomly selected from a large insurance carrier's national data source. An effort was made to select only uncomplicated cases, which would be expected to have relatively minimal need for medical intervention. There was an apparent overuse of diagnostic and treatment modalities. Diagnostic imaging was overutilized, not only in terms of the number of studies done (65% had plain films, 22% had magnetic resonance imaging scans) but also in the time frame in which they were performed (38% had plain films on the first clinic visit). Ninety percent received at least one medication, and 38% received more than one prescription for opioid analgesics. Expensive non-steroidal anti-inflammatory drugs were prescribed more often than acetaminophen (61% versus 6%, respectively). Sixty-two percent received physical therapy that often included modalities with as yet unproven efficacy. Overutilization of either diagnostic or treatment procedures increases the likelihood of iatrogenic complications, is not cost-effective, and may adversely impact clinical and occupational outcomes.

Adolescent↗
PubMed1988

Private cost containment. The effects of utilization review programs on health care use and expenditures.

Utilization review has been regarded as one of the most promising approaches to the containment of health care costs. We analyzed insurance claims data on 222 groups of employees and dependents for 1984 and 1985 to evaluate the effects of utilization review programs instituted by a large private insurance carrier. The utilization review programs we studied were compulsory; patients who did not follow established utilization review procedures were subject to financial penalties. Controlling for employee characteristics, health care market area factors, and benefit-plan features, we found that utilization review reduced admissions by 12.3 percent, inpatient days by 8.0 percent, hospital expenditures by 11.9 percent, and total medical expenditures by 8.3 percent. When only groups that had relatively high admission rates before adopting utilization review were analyzed, it was found that they had a 34 percent reduction in patient days and a 30 percent reduction in hospital expenditures. The savings-to-cost ratio of utilization review for groups overall was highly favorable--approximately 8 to 1. Private utilization review programs of the type we studied appear to be effective in reducing hospital use and decreasing medical expenditures. This study did not address the possible effects of such programs on the health status of patients.

Cost Control↗
PubMedDate not supplied

Surgical training in a statutory health insurance system: Belgian experience.

Health care delivery in Belgium is based on a compulsory insurance system, installed and controlled by the government since 1945 for employees; in 1963 the system was expanded to include self-employed citizens. Mutual benefit organizations act as insurance carriers for all patients, whether cared for in the office or hospital. The cost of state-financed medical care has grown to such an extent during the last few decades that cost-sharing in ambulatory practice is being extended to in-clinic services. The free choice of practitioners as well as free access to medical and specialist education have always been keystones of the Belgian medical care system. A well regulated scheme of surgical training combined with strict rules imposed on instructors, hospitals, and trainees guarantee high quality and state-controlled surgical education. Developments in the Belgian political landscape may considerably affect health care delivery and surgical education. A constant rise in the number of medical practitioners and the sociopolitical discrepancies between the Flemish and French speaking parts of the federalized kingdom have paralleled burgeoning medical health care costs and have induced rationalization and possibly federalization of health care delivery as well as ongoing debates concerning the limitation of medical and surgical practitioners.

Belgium↗
PubMed1994

Positron emission tomography: a financial and operational analysis.

Positron emission tomography (PET) is an emerging clinical imaging technique that is facing the challenges of expansion in a period of imminent health care contraction and reform. Although PET began showing utility in clinical medicine in the mid-1980s [1], its proliferation into mainstream medical practice has not matched that of other new imaging technologies such as MR imaging. Many factors have contributed to this, including the changing health care economy, the high cost of PET, the length of time it takes to develop a PET facility, and its inherent complexity. In part because of the proliferation of the use of other technologies and the general explosion of costs, insurance carriers are now holding diagnostic techniques, including PET, to stricter standards of efficacy. New techniques must show improvement in long-term outcome of patients, a difficult task for diagnostic tools. In addition to these issues, PET is an expensive technology that requires highly trained multidisciplinary personnel. Questions have also been raised about the most appropriate mechanism for regulation of PET isotope preparation, leading to speculation about future regulatory requirements. The current pioneers of PET must meet these challenges in order for it to become a routine imaging technique. Because of its clinical value, PET will probably survive despite the challenges. For many reasons, though, not every hospital should necessarily develop PET services. Conversely, many hospitals without this technology should consider acquiring PET. The purpose of this article is to identify the financial, operational, and clinical challenges facing PET centers today, describe potential organizational configurations that may enable PET to survive in an antitechnology environment, and delineate which institutions should consider this new technology.

Ambulatory Care Facilities↗
PubMed1991

Malpractice claims data as a quality improvement tool. II. Is targeting effective?

OBJECTIVE: --To evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors. DESIGN: --Retrospective review of physician malpractice claim records. SETTING: --Large New Jersey physician malpractice insurer. PARTICIPANTS: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, or radiology and covered by the insurance carrier for any portion of 1977 through 1989. MAIN OUTCOME MEASURES: --Claims were classified into 11 clinical error categories comprising three broad groups: patient management problems, technical performance problems, and staff coordination problems. Outcomes were expressed as per-physician frequency of claims due to negligence and proportion of claims associated with various types of errors. RESULTS: --Using 5 years of claims history to predict long-term claims proneness was more accurate than chance alone by 57% in obstetrics and gynecology, 33% in general surgery, 11% in anesthesiology, and 15% in radiology. Cross-validated recursive partitioning showed that among physician characteristics, only specialty was predictive of physician error profiles. For physician claims arising in acute care hospitals, hospital size and location in addition to hospital services discriminated among different error profiles; the cross-validated accuracy of this method was 69% compared with 22% accuracy achieved by random prediction. CONCLUSION: --Use of physicians' malpractice claims histories to target individuals for education or sanctions is problematic because of the only modest predictive power of such claims histories.

Anesthesiology↗
PubMed1998

Effect of payer status on outcomes of coronary artery bypass surgery in blacks.

BACKGROUND: Black patients with coronary artery disease have a higher mortality rate than white Americans. They also have a higher prevalence of hypertension, diabetes mellitus, and renal disease, which may have an effect on mortality rates. The deleterious effect of these comorbidities may be exacerbated by impaired access to secondary prevention strategies and longitudinal care. Therefore, the presence or absence of comprehensive care as indicated by payer status may then affect survival on surgically treated patients. In this study we examined the role of cardiovascular risk factors and insurance carrier status on early outcomes of coronary artery bypass grafting (CABG) surgery in blacks versus white Americans. METHODS AND RESULTS: From January 1990 to December 1996, 2776 patients (2003 men, 773 women; mean age 63 +/- 10 years), underwent isolated CABG in a multispecialty practice serving a major metropolitan population. There were 494 (17.8%) black patients and 2282 (82.2%) white patients. The proportion of black patients in each payer category was 17.8% commercial, 14.1% managed care, 52.9% Medicaid, and 19.5% Medicare. The effect of preoperative risk factors, including status of operation (elective, urgent, or emergent), sex, race, redo CABG, presence of renal disease, diabetes mellitus, congestive heart failure, myocardial infarction, the completeness of revascularization, age, and left ventricular ejection fraction were analyzed with the chi 2 test for categorical variables and the Student t test for age and ejection fraction. A multiple logistic regression analysis was performed to assess the effect of all variables on mortality rates simultaneously. Black patients had a higher incidence of diabetes mellitus, hypertension, and renal disease than white patients (P < 0.001). Overall, 30-day mortality rate was 2.5% (58 of 2282) in white patients versus 5.5% (25 of 494) for black patients (P < 0.003). Multivariate analysis showed that only emergency surgery status (OR 3.59, P < 0.01), redo CABG (OR 3.78, P < 0.001), hypertension (OR 2.32, P < 0.03), history of congestive heart failure (OR 2.1, P < 0.004), older age (OR 1.07, P < 0.001), and low ejection fraction (OR 0.98, P < 0.003) correlated with mortality rates. Race and payer status were not significant predictors of death. CONCLUSIONS: These data on CABG surgery in black patients suggest that early death is due to associated risk factors and not due to race or insurance payer status.

Black or African American↗
PubMed1991

Malpractice claims data as a quality improvement tool. I. Epidemiology of error in four specialties.

OBJECTIVE: --To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology. DESIGN: --Retrospective review of physician malpractice claim records. SETTING: --Large New Jersey physician malpractice insurer. PARTICIPANTS: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, and radiology and covered by the insurance carrier during any portion of 1977 through 1989. MAIN OUTCOME MEASURES: --Proportion of claims due to negligence associated with errors in (1) patient management, (2) technical performance, and (3) medical and nursing staff coordination and the clinical and financial consequences of such errors. RESULTS: --Among 1371 claims ascribed to negligence, patient management errors were cited most frequently in all four specialties (48% to 75%) and, compared with performance and coordination problems, were generally associated with a higher frequency of serious injury and higher median payments. Coordination problems accounted for about 9% of claims. In obstetrics and gynecology, newborn delivery claims usually arose from management errors (57% to 68%), whereas gynecologic procedure claims were most often associated with performance errors (55% to 73%). Underperformance of cesarean section was cited more frequently than overperformance (31% vs 3%). General surgery claims were about equally divided between management and performance types regardless of procedure. Failure to perform appropriate diagnostic testing or monitoring was the main problem in 3% to 8% of claims. CONCLUSION: --Malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence.

Anesthesiology↗
PubMed1994

Does reduced hospital stay affect morbidity and mortality rates following cleft lip and palate repair in infancy?

Insurance carriers affected decisions regarding admissions and length of stay in our hospital in 1987. Charts were reviewed retrospectively to determine whether this affected morbidity and mortality rates following cleft lip and palate operations in infants. Two periods were studied: May of 1983 through April of 1987 (group I) and April of 1987 through May of 1991 (group II). A total of 248 infants with cleft lip and/or palate underwent 398 operations: lip adhesion (74), definitive lip repair (130), and palatoplasty (194). Half were performed in each period. Admission status, length of stay, length of operation, and short-term morbidity were documented. Morbidity included spontaneous and traumatic lip dehiscence, palatal dehiscence, and palatal fistula. Intergroup analysis was performed by the chi-squared method; p < or = 0.05 was statistically significant. In group I, 93 percent of patients were admitted before surgery. In group II, 5 percent were admitted before surgery and 79 percent the day of surgery. Hospital stay decreased nearly 2 days for each operation. There was no statistically significant difference between groups in distribution of operations, length of operations, or morbidity: lip surgery complications (p = 0.263), palatoplasty complications (p = 0.624). Reductions of hospital admissions and length of stay do not affect outcome of cleft lip and palate surgery in infants. The reduction in hospital days is equivalent to a savings of $138,000 (1991 dollars).

Ambulatory Surgical Procedures↗
PubMedDate not supplied

The first private sector health insurance company in Ghana.

This article analyses the development of Ghana's first private sector health insurance company, the Nationwide Medical Insurance Company. Taking both policy and practical considerations into account (stakeholders' perspectives, economic viability, equity and efficiency), it is structured around key questions which help to define the position and roles of stakeholders--the insurance agency itself, contributors, beneficiaries, and providers--and how they relate to one another and the insurance scheme. These relationships will to a large extent determine Nationwide's long-term success or failure. By creating a unique alliance between physician providers and private sector companies, Nationwide has used employers' interest in cost containment and physicians' interest in expanding their client base as an entrée into the virgin territory of health insurance, and created a hybrid variety of private sector insurance with some of the attributes of a health maintenance organization or managed care. The case study is unusual in that, while public sector programs are often open to academic scrutiny, researchers have rarely had access to detailed data on the establishment of a single private sector insurance company in a developing country. Given that Ghana is planning to launch a national health insurance plan, the article concludes by considering what the experience of this private sector initiative might have to offer public sector planners.

Cost Control↗
PubMedDate not supplied

Revitalizing a documentation system.

The nursing department of a 154-bed acute rehabilitation facility, cognizant of the changing trends in health care and responding to feedback from staff, developed and implemented a comprehensive documentation system. The previous system had been fragmented, inconsistent, and inefficient. The development of the new system focused on the complex needs of the rehabilitation client and the equally complex standards required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), and insurance carriers. The final product, which was based on the nursing process and functional health patterns, encompassed the following areas from admission to discharge: providing feedback on clients' functional abilities and progress toward goals, satisfying requirements of the 1990 JCAHO standards, and, finally, using a flow sheet that saves nursing time and increases objectivity. This article describes the system from conceptualization to successful implementation.

Humans↗
PubMed1992

Captive insurance companies in health care.

A health care system or individual hospital should consider establishing a captive insurance company if any one of the following situations exist: The organization's professional liability program is arranged with a self-insured retention of $500,000 or more, or consideration is being given to such an arrangement. A trust fund has been established for a self-insured exposure--professional liability, workers' compensation, or employee benefits. A portion of the organization's professional liability excess insurance program is arranged with an insurer that uses a fronting insurer. The organization currently sponsors, or is considering sponsoring, a physicians' liability insurance program for medical staff members. If any of those situations exist, a comprehensive feasibility study should be undertaken, preferably by an independent, objective organization that does not have a financial interest in the outcome of the study.

Costs and Cost Analysis↗
PubMed1993

A mandatory physician loss prevention seminar.

In summary, this article has reported on the experience of a mandatory physician loss prevention seminar that is sponsored by a professional liability company. The article includes only highlights of the seminar program; by no means is it a detailed report. Also, the literature cited in the references is hardly an exhaustive search. Implications for the development, implementation, and evaluation of a hospital-based seminar program were both implicitly and explicitly discussed, as were some of the seminar's limitations, both within the seminar and its evaluation. It is hoped this article will stimulate health care risk managers to either develop their own seminars or modify certain aspects of their existing seminars, both for their medical staff and hospital (employee) staff. Involvement in risk management/loss prevention seminars are both educational and challenging for the professional health care risk manager. They may also prevent claims, conserve the institution's financial resources, prevent patient injury, and improve the quality of patient care delivered.

California↗