Omission-related malpractice claims and the limits of defensive medicine.
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Defensive Medicine↗
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Results for “Insurance Claim Review”
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Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis.
OBJECTIVE: Poor compliance and persistence with bisphosphonates is a concern in postmenopausal osteoporosis due to its negative impact on fracture risk and healthcare costs as well as quality of life. Reducing oral bisphosphonate dosing frequency is one measure available to increase therapy convenience and practicality, with the hope of improving compliance and persistence. This study compared compliance and persistence with weekly and daily bisphosphonate regimens for postmenopausal osteoporosis. METHODS: Administrative claims data (1997-2002) from 30 health plans were used to identify postmenopausal women (> 45 years) with osteoporosis, who had been newly prescribed a once-weekly (QW alendronate 35 mg or 70 mg) or once-daily (QD alendronate 5 mg or 10 mg or risedronate 5 mg) bisphosphonate. QW and QD cohorts were followed for 12 months from initial prescription. Medication possession ratios (MPRs) measured refill compliance during follow-up. Persistence was calculated as the number of days from the initial prescription to a lapse of > 30 days after completion of the previous refill. RESULTS: Data were available for 2741 women (QW, N = 731, QD, N = 2010). QW users had significantly higher medication compliance than QD users (69.2% vs. 57.6% MPR, p < or = 0.0001). QW users persisted with therapy significantly longer than QD users (p < 0.0001) and had higher rates of retention on treatment at 12 months than QD users (44.2% QW; 31.7% QD). Dosing frequency was the strongest predictor of time to discontinuation (p < 0.0001). CONCLUSIONS: Postmenopausal women prescribed a weekly bisphosphonate had significantly better compliance and persistence than those taking more frequent, daily bisphosphonate doses. However, compliance and persistence rates for both regimens were suboptimal, suggesting that less frequent dosing intervals may provide an opportunity to further improve the consistent use of bisphosphonate therapy.
Age Factors↗
When do health care decisions discriminate against persons with disabilities?
Recent interpretations of laws prohibiting discrimination against persons with disabilities indicate that these laws will play a greater role in health care decision making than previously anticipated. This article employs lessons from other areas of antidiscrimination law to examine these developments and to provide a framework for making health care decisions that are consistent with these new legal interpretations. This article addresses decisions in individual cases, treatment policies adopted by health care providers, and coverage programs of third-party payers, both public and private.
Algorithms↗
Compensation for medical injury in New Zealand: does "'no-fault" increase the level of claims making and reduce social and clinical selectivity?
The issues of patient safety and quality of care have gained policy attention with a growing appreciation of the scale and impact of medical injury in health systems. While the focus is clearly on the prevention of iatrogenic injury, the question of patient compensation is now also considered important, if only because in fault-based tort systems the fear of litigation may itself be a barrier to the disclosure and open discussion of medical error. No-fault systems, by contrast, do not require proof of culpability, and thus may both reduce barriers to compensation and increase disclosure of error. Little evidence, however, is available on the performance of such systems. This article reports on the analysis of two data sources-a sample of hospital admissions and a complete set of compensation claims for medical injury. Both are for the same year and region of New Zealand, a country that has maintained a no-fault system of accident compensation for a quarter of a century. Just over 2 percent of hospital admissions were associated with an adverse event that was potentially compensable under scheme criteria. While the claims process was well targeted, the level of claims making and receipt was low, with the ratio of successful claims to potentially compensable events being approximately 1:30. Comparison of social and clinical characteristics of the two data sets revealed a degree of selectivity. Compared with the hospital events, the typical successful claimant was younger and female and was much more likely to have experienced a surgical adverse event that, while unexpected, was not due to substandard care. It is concluded that, in interpreting these results, account needs to be taken of a number of features unique to the New Zealand system. These include: the limited payoff for a compensation claim (no pain and suffering or lump sum, free hospital care); the relative complexity of the grounds for claim (either rarity and severity or practitioner error); and a history of limited litigation for medical error. This suggests that, while the New Zealand system is well targeted, cheap, and free of financial and legal barriers, a change in legal doctrine alone has not in itself been sufficient to remove completely the selective and low level of claims making traditionally associated with patient compensation under tort.
Adult↗
Variation in specialist fees: evidence from New Zealand insurance claims.
OBJECTIVES: To examine the parity between specialties in reimbursements for surgical procedures in a private, fee-for-service setting and to ascertain whether differences exist after accounting for factors suggested by a Resource-Based Relative Value Scale (RBRVS). METHODS: A routinely updated database covering several private insurers (n = 8294 procedures from 1997 to 2002) was used to examine differences in overall and hourly reimbursement. Multiple regression analysis was used to control for factors that might be responsible for differences in payment (location, year, sex of patient and the associated anaesthetist fee). The resulting regression residuals were compared between specialties. RESULTS: Large differences between specialties in reimbursements were found in the overall amount paid. For most specialties, these differences were explained by factors such as time for procedure, location, complexity of procedure and sex of patients. However, hourly reimbursements for ophthalmologists were substantially higher (more than 50% above general surgery overall and 72% higher on an hourly basis). Some other smaller differences in overall and hourly reimbursement were also found. CONCLUSIONS: These results indicate that specialist fees vary significantly but many of the differences are explainable by factors incorporated into the RBRVS. However, significant variation remains for some specialties, most notably ophthalmology. Explanations for the results are discussed, including the possibility that political factors may influence the setting of specialist fees. This raises questions concerning the fairness of reimbursements and resulting solidarity within the medical profession.
Fee-for-Service Plans↗
Reducing health care cost by demarketing benefits.
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Community Participation↗
Community and ambulatory pharmacy: evaluation of patient care services and billing patterns before implementation of Medicare part D.
OBJECTIVE: To provide a summary of community and ambulatory pharmacy practice and billing patterns for medication therapy management services before implementation of Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). DESIGN: Cross-sectional survey. SETTING: Ambulatory care and community pharmacy practice settings in the United States in January 2004. PARTICIPANTS: Members of the American College of Clinical Pharmacy Ambulatory Practice and Research Network, preceptors of the American Pharmacists Association (APhA) Community Pharmacy Residency Programs, and participants in the APhA Immunizing Pharmacist listserv. INTERVENTIONS: E-mail invitations to participate in a Web-based survey. MAIN OUTCOME MEASURES: Practice setting; pharmacy services performed; whether pharmacists were billing for pharmacy services; if billing, the billing technique used; if not billing, the reason for not billing. RESULTS: Of 349 respondents, 127 (36.4%) were practicing within a physician office, while 121 (34.7%) were practicing in community pharmacies. Diabetes, anticoagulation, dyslipidemia, hypertension, and smoking cessation management services were performed significantly more often in physician offices. Immunization delivery and diabetes, dyslipidemia, and osteoporosis screenings were performed significantly more often in community settings. A total of 190 (54.5%) pharmacists stated that they were billing for pharmacy services. More community pharmacists were billing for services compared with other combined practice settings (69.2% versus 46.7%, P < .001). Top reasons identified for not billing for services were salaried position, indigent population, and discomfort with the billing process. CONCLUSION: Valuable baseline data are provided regarding pharmacy services that have been successfully implemented in ambulatory and community practice settings and which billing techniques were used to receive reimbursement before the implementation of MMA.
Ambulatory Care↗
Changing prescribing patterns and increasing prescription expenditures in Medicaid.
PURPOSE: Prescription drug expenditures are the most rapidly growing component of total health care expenditures and particularly affect state Medicaid programs. We determined the extent to which increasing prescription price and changing prescribing patterns contribute to rising prescription expenditures in Medicaid. METHODS: We conducted a claims-based analysis comparing annual prescription drug expenditures and prescribing patterns. Prescription drug and outpatient visit claims for all North Carolina Medicaid enrollees from 1998 through 2000 were included. We analyzed drugs individually by combining all prescriptions and expenditures for the same drug formulation, and we calculated the number of units dispensed per person-year of enrollment. RESULTS: Prescription drug coverage for 1 person-year cost 503 dollars in 1998 and 759 dollars in 2000, for an annual increase of 22.8%. The average number of prescriptions filled per person-year increased from 13.0 in 1998 to 15.5 in 2000. Increased prescribing for 6 drugs accounted for more than 25% of the total increase in expenditures. The price for the 15 most expensive drugs increased an average of 4.1% annually. CONCLUSIONS: Prices for existing drugs increased slightly during the study period, but the major cause of the increase in drug costs was an increase in the number of prescriptions for new and more expensive medications. Prescribing patterns in Medicaid differ somewhat from those in the private sector and partly reflect the population with low socioeconomic status and high health care needs that it serves. To help control rising prescription drug expenditures, efforts should be undertaken to improve appropriate and cost-effective prescribing.
Adult↗
Inside the black box of administrative costs.
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Costs and Cost Analysis↗
Use of the resource-based relative value scale for private insurers.
Medicare's resource-based relative value scale (RBRVS) was implemented 1 January 1992 for physician payment using a conversion factor of $31 for each relative value unit (RVU). We calculated a conversion factor of $42.24 for The Travelers Insurance Company's group health plan business using the RBRVS methodology and the calendar year 1990 Travelers Large Case Norms Extract of active employees. This DataWatch describes two important applications of the relative value scale for private insurers: for pricing and for analyzing claims expenditures.
Cost Control↗
The questionable value of medical screening in the small-group health insurance market.
Insurers perform medical screening to assess risk for health insurance in the small-group market. Most reform proposals eliminate screening because it denies coverage to those who need it. This DataWatch empirically analyzes the value of medical screening to insurers. We analyzed claims of two employed populations covered by a large insurer--one screened and the other not screened. We found no significant difference in the amounts claimed by these two populations over six years. This suggests that medical screening could be eliminated in the small-group market without an increase in premiums.
Data Collection↗
No-fault compensation for medical injury: a case study.
Changes in malpractice law remain an important goal of health care reform. Many state and federal legislators continue to call for measures that would limit the ability of injured patients to sue. There is also growing interest in alternatives to fault-based litigation. As legislators consider no-fault proposals, they can look to Florida's experience with the Neurological Injury Compensation Association (NICA), which for the past four years has been providing no-fault compensation for injured newborns. NICA provides some insights into the ways in which claims are generated, the nature of risk spreading, and the financial viability of a no-fault model.
Birth Injuries↗
Medical necessity: do we need it?
The term medical necessity has been mainly a placeholder in insurance plans for over thirty years. More recently, the national health care reform debate and litigation over denials of costly experimental treatments have broken the term out into open discussion about what a necessary service is and who should decide if it is covered. This paper summarizes the history of the term and its evolution from an insurance concept controlled by practicing physicians to a rationing tool used by insurance administrators. How did national reform efforts address this terminology, and how should we define medical necessity in a changing delivery system?
Decision Making↗
Are small firms greater health risks?
To test whether use of health care services is a function of firm size, we analyzed a three-year database (1988-1990) of private insurance claims, representing 28,990 firms and approximately 1.4 million subscribers in western Pennsylvania. In this database both small and large firms had higher medically underwritten costs than mid-size firms had. Furthermore, risk-pooling alternatives that included small companies had a lower cost per subscriber than the risk pools that included large companies, especially companies of more than 500 contract holders. Age, sex, health status, and the types of hospitals used for inpatient care of pooled subscribers, in combination, were found to be the important determinants of costs. With risk adjustment based on these factors to correct for adverse risk selection, community rating can be a feasible approach to increasing the affordability and accessibility of health insurance to the majority of those who lack it.
Adult↗
The Internet and managed care: a new wave of innovation.
Managed care firms have been under siege in the political system and the marketplace for the past few years. The rise of the Internet has brought into being powerful new electronic tools for automating administrative and financial processes in health insurance. These tools may enable new firms or employers to create custom-designed networks connecting their workers and providers, bypassing health plans altogether. Alternatively, health plans may use these tools to create a new consumer-focused business model. While some disintermediation of managed care plans may occur, the barriers to adoption of Internet tools by established plans are quite low. Network computing may provide important leverage for health plans not only to retain their franchises but also to improve their profitability and customer service.
Case Management↗
The decline in receipt of substance abuse treatment by the privately insured, 1992-2001.
This study examines underlying trends in substance abuse services financed by private insurance. Analyses are based on the 1992 and 2001 Medstat MarketScan database, a claims database from large employers. The percentage of beneficiaries using any substance abuse services declined by 23 percent from 1992 to 2001 (from 0.64 percent of enrollees to 0.49 percent of enrollees). This decline was evident in all categories: inpatient, outpatient, and pharmaceutical usage. Substance abuse spending per covered life (in constant dollars) dropped from about $21.16 in 1992 to about $5.58 in 2001 [corrected]
Adolescent↗
Variability and growth in spending for outpatient specialty pharmaceuticals.
Specialty pharmaceuticals are a unique group of drug agents used to treat complex clinical conditions. Many specialty pharmaceuticals are biological in nature and administered through injection or infusion. Tracking spending on these pharmaceuticals is complex, because these products may be processed as either medical or pharmacy claims. This benchmarking study of ten Blue Cross Blue Shield plans, representing almost eighteen million covered lives, documents large expenditures on select specialty pharmaceutical categories and much variation in spending across plans, age groups, and time. Our results underscore the need for insurers to scrutinize trends in specialty pharmaceutical spending and identify appropriate management strategies.
Adult↗
Access to cancer drugs in Medicare Part D: formulary placement and beneficiary cost sharing in 2006.
The Medicare Part D benefit expands the universe of cancer drugs and biologics that Medicare may cover. Individual Part D plans have discretion to determine their formularies and cost sharing for drugs within federal guidelines. This paper analyzes differences in coverage and cost sharing for cancer drugs among these plans. We find that many cancer drugs, including brand-name products, are covered by almost all plans, although prior authorization might limit access to some. In addition, many plans charge a relatively low copayment for most cancer drugs. These findings suggest that Part D could greatly expand beneficiaries' access to cancer treatments.
Biological Products↗