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At least 307 records · Page 17Linked to original sources
PubMed2000

Is fibromyalgia a distinct clinical syndrome?

The validity of the fibromyalgia syndrome (FMS) as a distinct clinical entity has been challenged for several reasons. Many skeptics express concern about the subjective nature of chronic pain, the subjectivity of the tender point (TeP) examination, the lack of a gold standard laboratory test, and the absence of a clear pathogenic mechanism by which to define FMS. Another expressed concern has been the relative nature of the pain-distress relationship in the rheumatology clinic. The apparently continuous relationship between TePs and somatic distress across a variety of clinical disorders is said to argue against FMS as a separate clinical disorder. The most aggressive challenges of the FMS concept have been from legal defenses of insurance carriers motivated by economic concerns. Other forms of critique have presented as psychiatric dogma, uninformed posturing, suspicion of malingering, ignorance of nociceptive physiology, and occasionally have resulted from honest misunderstanding. It is not likely that a few paragraphs of data and logic will cause an unbeliever to change an ingrained opinion. Therefore, this review describes the clinical manifestations of FMS, responds to some of the theoretic arguments against it, and discusses some possible pathophysiologic mechanisms by which FMS may develop and persist as a unique syndrome.

Autonomic Nervous System↗
PubMed1996

Infertility treatment dropout and insurance coverage.

OBJECTIVE: To assess early patient dropout rates during infertility treatment as a potential measure of wasted resources. METHODS: The study involved multifaceted population cohorts, including a prospectively observed captive health maintenance organization (HMO) population and retrospectively selected preferred provider organization (PPO) patients. One hundred twenty-eight HMO couples were followed prospectively for 6 months. The insurance carrier retroactively selected 96 couples from their PPO population who were believed to be infertility patients. They were matched by date, age, and time of hysterosalpingography to infertility patients in the carrier's HMO population. Patients were considered treatment dropouts if they either requested their provider to abandon further work-up or treatment, or if they failed to return for an appointment for 3 months. RESULTS: Forty-six of 128 (36%) HMO patients followed prospectively discontinued care within 180 days, with only eight (6.3%) providing defined reasons. Preferred provider organization patients uniformly demonstrated significantly higher dropout rates than HMO patients, a finding already apparent at 60 days (P < .002; odds ratio [OR] 3.67, 95% confidence interval [CI] 1.47-9.97) and 120 days of treatment (P = .002; OR 2.87, 95% CI 1.39-6.06). Among PPO patients, dropout rates were especially pronounced if infertility care was provided by generalists. At billing levels of at least $2000, HMO patients also demonstrated less dropout than PPO patients (P < .001; OR 6.14, 95% CI 2.72-14.79), with generalists again demonstrating a significantly larger patient loss than infertility specialists (P < .001; OR 0.18, 95% CI 0.66-0.49). CONCLUSION: Infertility patients demonstrate a surprisingly large early dropout rate, which is significantly larger if patients receive infertility care from generalists rather than specialists. Newly presenting infertility patients should be carefully evaluated, especially in indemnity situations, before expensive diagnostic and therapeutic interventions are ordered.

Adult↗
PubMed1992

Competitive bidding for health insurance contracts.

The determination of the payment or premium to be paid to the insurer by a large purchaser of care must accurately represent the risk of the enrolled persons. One approach is a risk-adjusted payment established by a mathematical formula, which estimates the effect of many variables on total care costs, and for different groups of persons determine an average cost. This method has several problems, and an alternative is competitive bidding. Market forces pressure providers to offer the lowest possible bids while attempting to remain fiscally viable and provide high-quality services. Research from the U.S. demonstrates that competitive contracting effectively lowered the costs of health care for those sectors of the health care system that used this strategy. Bidding by area gave far more equitable results than could have been obtained with a state-wide system with crude adjustments for each area. It is an alternative which can create strong incentives for innovation and cost-containment, and at the same time allows insurers to take into account local variation in supply and demand of care. As a potential alternative to a regulatory system, competitive bidding should be considered for regional experimentation in health insurer payment.

Actuarial Analysis↗
PubMed1995

Success, failures and costs of implementing standards in the USA--lessons for infection control.

In the US, extensive standards for performance and 'guidelines for practice' have been instituted by a number of governmental and non-governmental agencies. New governmental plans for health care depend heavily on practice guidelines, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has been especially enthusiastic about continuous quality improvement. Monitoring the appropriateness of care and altering physician practice appeals to insurance carriers and health care management organizations. Some initial data exist to show that the quality of health care has been enhanced by these regulations. The total cost for health care administration in 1990 in the USA was 24.8% of each hospital's spending for health care. Much of this was associated with spending for new initiatives in practice guidelines, physician profiling, quality assurance, and the like. Few data exist to show that the quality of health care or hospital infection control has been enhanced by these expenditures. Regulations and guidelines also have proliferated in infection control. Guides from the JCAHO have been expanded, and recent mandates from the Occupational Health and Safety Administration (OSHA) for protecting employees from blood-borne and respiratory pathogens promise to be especially costly for health care organizations to implement. Little data exist to show that the quality of infection control has been enhanced by these regulations. Standards are difficult to develop, because the science to back them up often is lacking, interpretation of validating data is imprecise, and inherent biological variation makes exceptions common. Seven lessons are important for those developing standards today. These include focusing on objective measures of the impact of the standard, clearly indicating the degree of scientific validity, making the development process inclusive, allowing for local variation, making sure that funding is provided for mandated standards, considering non-scientific implications of standards, and remaining involved in the process after the guideline is developed. Infection control workers should make sure that standards developed take the lessons above into account before they are promulgated.

Financial Support↗
PubMed1982

Insurance, competition and cost containment.

Most economists have suggested that the growing presence of insurance, including Medicare, Medicaid, Blue Cross and the commercial insurers, is largely responsible for the rapid rise of health care costs in the United States. It is the contention of this paper, however, that the insurance industry in the private sector in the United States may help in the effort to contain costs rather than solely stimulating rapidly increasing costs. A number of methods that insurers have employed to contain costs, including monitoring provider behavior and prospective reimbursement, are identified. It is cautioned, however, that although health insurer cost containment efforts will continue to expand in the future, perversities in the U.S. tax laws, potential provider opposition and the complexities of medicine will continue to make cost containment a difficult task.

Cost Control↗
PubMed1993

A psychosocial and behavioral comparison of reflex sympathetic dystrophy, low back pain, and headache patients.

Based primarily on anecdotal evidence, patients with reflex sympathetic dystrophy (RSD) have often been suspected of having a high degree of psychosocial disturbance prior to the onset of symptoms as well as in reaction to the disorder. In the present study, patients presenting to a pain center with RSD were compared to patients with low back (LBP) and headache pain (HAP) on a variety of self-reported demographic, behavioral, pain, and mood measures. Typical of most patients experiencing chronic pain, all three groups demonstrated elevations indicative of pain, emotional distress, and behavioral disturbance. However, although the RSD patient group reported the highest level of pain intensity, the most employment disruption, and contained the highest percentage of patients receiving financial compensation, this same group paradoxically reported less emotional distress on the Symptom Checklist-90R than did LBP and HAP patients. This paradox may be due to the lesser chronicity of the RSD patients as well as to their apparently experiencing a more sympathetic response from doctors, employers, and insurance carriers than their LBP and HAP counterparts. On balance, the present data do not support the hypothesis the RSD patients, relative to other pain patients, are uniquely disturbed in psychosocial functioning.

Adult↗
PubMed2004

The impact and enforcement of prudent layperson laws.

STUDY OBJECTIVE: Almost every state has enacted a "prudent layperson" standard for determining insurance coverage for emergency department (ED) services. This study evaluates whether these laws are achieving their goals or causing unintended side effects. METHODS: Six states were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 11 to 15 interviews were conducted with insurers, regulators, providers, employers, patient advocates, and industry observers, for a total of 87 interviews. In addition, regulators in all 50 states completed a written survey about likely enforcement responses for hypothetical violations of these laws. RESULTS: Basic compliance with prudent layperson laws appears to be widespread. Regulators actively enforce these laws, and most subjects reported no systematic violations. Insurers explained that it is difficult to operationalize a coverage standard that relies on patients' experience of symptoms rather than on providers' assignment of diagnostic and procedure codes. No strong evidence was found that these laws have significantly increased insurance costs, which is due in part to various strategies insurers have adopted to reduce payments to providers for ED services and to greatly increase patients' copayments. Accordingly, few subjects believe these laws have increased inappropriate ED use. CONCLUSION: Prudent layperson laws have helped to catalyze industry-wide changes in how health insurers review ED claims and how they manage ED costs. Whether these changes, on balance, are beneficial to patients and to society requires further study focused on outcomes and system-wide costs.

Emergency Service, Hospital↗
PubMed2004

Workers' compensation fraud and the physician.

Some individuals in the health care system base their actions primarily on individual economic incentives rather than ethical and societal standards. These actions are considered fraudulent when they can be proven to have violated specific laws or statutes and can impact workers' compensation costs. Physicians and other health care providers involved in the management of workers' compensation claims may have little ability to affect employer or insurer fraud. Ethical and efficient practice style, in conjunction with the maintenance of clarity and objectivity in the evaluation of patient symptoms, can help to reduce the degree to which provider and patient fraud is allowed to develop and flourish. In understanding the factors that promote fraudulent behavior and being able to recognize and manage such behavior, health care providers may impact the perpetuation of fraud and its impact on the workers' compensation system.

Fraud↗
PubMed2006

Therapeutic uses of double-balloon enteroscopy.

In spite of initial skepticism toward the practicability of double-balloon enteroscopy, this technology will become an integral part of endoscopy and is likely to find expanded applications in the future. One strong reason to support this technique is the capacity to deliver endoscopic therapies, and thereby minimize aggressive surgical options. With increasing acceptance of capsule endoscopy by the medical community, more small-bowel lesions will be found and more directed endoscopic interventions will be needed. Like many new procedures, reimbursement issues will possibly prevent it from gaining well-deserved popularity. Unlike other common endoscopies, double-balloon enteroscopy is an expensive procedure. It requires fluoroscopy, extended anesthesia support, long procedure time, significant capital investment, and a team of threeor four people (endoscopist, anesthesiologist, nurse). Gastroenterologists and their patients will have to work together to convince insurance carriers that this isa valuable and cost-effective technology worthy of appropriate reimbursement.

Catheterization↗
PubMed2005

A history and overview of the certification exam for medical dosimetrists.

During the last century, the creation and implementation of board certification has had a powerful impact on the medical community. Board certification has helped to shape the scope and practice of medical professionals and the care they provide, as well as to influence the way the health insurance industry sets standards for reimbursement. One profession that offers board certification to its members is medical dosimetry. The Medical Dosimetrist Certification Board exam has been administered since 1988 and its content covers a broad spectrum of information from the radiation therapy sciences. The exam has strict application requirements and is rather difficult to pass. Those who pass the exam can then call themselves Certified Medical Dosimetrists. For data purposes of this study, several members of the dosimetry community were solicited to participate in a survey regarding the exam's content and history, and to provide relevant statistical data. Currently 2,177 medical dosimetrists are board certified, with an additional 1,500 estimated to be working without certification. Although board certification is not currently required to practice medical dosimetry, new legislation known as the CARE Bill could change this. The CARE Bill, if passed, would mandate nationwide compulsory licensure and/or certification for medical dosimetrists and other medical professionals who want to work in radiation-related health care. Health maintenance organizations and other insurance carriers may likewise require certification for reimbursement purposes.

Certification↗
PubMedDate not supplied

Health insurers' medical necessity determinations for bariatric surgery.

PURPOSE: This study explored how state managed-care patient protection laws affect health insurers' criteria for medical necessity, using bariatric surgery for weight reduction as a case in point. METHODS: Six states and three national insurers were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 10-12 qualitative interviews were conducted in 2002 with insurers, regulators, providers, and healthcare attorneys, for a total of 71 interview subjects. RESULTS: Denials of coverage for bariatric surgery are a frequent source of appeals to external review, and external reviewers frequently overturn these denials. However, few insurers feel pressured to approve most or all requests for coverage because external review decisions do not set binding precedents. Instead, insurers continue to assert their own criteria for medical necessity, relying on the insurance contract's general definition of medical necessity. Some insurers, however, specifically exclude all weight reduction surgery because of the difficulty of defending case-by-case denials on appeal. CONCLUSIONS: Unlike most areas of medicine, in which health insurers have greatly scaled back their past efforts to scrutinize medical necessity, for bariatric surgery, many insurers continue to apply a more stringent standard for medical necessity than the one that independent practicing physicians use.

Bariatric Surgery↗
PubMed2006

Making the normal deviant: the introduction of predictive medicine in life insurance.

Over the past years, one of the most discussed topics in policy debates on genetics has been the use of genetic testing in insurance. Many of these debates have been rather speculative and abstract. In a recent contribution to this journal, Kaufert therefore urged for "a proper research agenda" to study the issue, arguing for the need of anthropological and sociological research of the insurance world. This article will make a start with this. Based on ethnographic fieldwork in two Belgium insurance companies, this study analyses the ways insurers account for predictive medicine (lifestyle, genetics) during underwriting. We demonstrate how insurers highlight predictive lifestyle health information and how this articulates with a fault based approach in underwriting. Individual responsibility for health risks becomes the golden standard for assessing one's fitness for membership of the insurance pool. Moreover, these developments imply a changed concept of "normal standard" in insurance, increasing the conditions to fulfil to be part of the insurance group. Predictive medicine constitutes new ground in the old debates about individual control, responsibility and blame for health. This goes to the heart of the basis for citizenship and how this articulates with membership--or, if you want, exclusion--of the insurance pool.

Belgium↗
PubMed1989

Endoscopic retrograde cholangiopancreatography. A diagnostic outpatient procedure.

Increased numbers of diagnostic ERCPs will be performed in ambulatory surgery units because the patient's needs can be accommodated safely and efficiently in outpatient care centers, and insurance carriers and Medicare providers currently have guidelines for reimbursement purposes only if the patient has the procedure as an outpatient.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

The potential impact of the resource-based relative value scale on the practice of nuclear medicine.

The Resource-Based Relative Value Scale (RBRVS) is finally here. A system designed to equate physician work across the specialties, it has its own peculiar and unique problems. Modeling of the system was based on the single physician-patient interaction; it may not work properly for laboratory specialties. There are other unique considerations concerning how the model was constructed. Although data were collected specifically for nuclear medicine, they were not used in the final computations. There is disagreement over whether those data would benefit or hurt nuclear medicine reimbursement. As presently implemented, the RBRVS poses grave dangers for the future of nuclear medicine. These dangers come not only in the professional reimbursement section of the rules but in the technical component areas as well. Estimates for reduction of income by 1996 range as high as 55% for nuclear medicine. When one factors the implementation of the RBRVS by independent insurance carriers into the equation, the entire economic future becomes muddy. A brief historical review of the RBRVS, as well as discussion of potential future implications of this type of reimbursement system, is presented. Prognostication is at least as inexact a science as reimbursement. Hopefully, the author's outlook on the future of nuclear medicine is more pessimistic than it need be.

Cost Control↗
PubMed1992

Evaluation of coronary artery disease with positron emission tomography.

Positron emission tomography (PET) represents the most sophisticated imaging modality in nuclear medicine allowing quantification of regional tracer tissue concentrations. Beside the technical superiority of data acquisition, a large number of PET radiopharmaceuticals are available for clinical application. Based on currently available data, PET provides detection of coronary artery disease with higher diagnostic accuracy than conventional thallium-201 single positron emission computed tomography. Applications of PET with metabolic tracers have been shown to provide clinically important information in the management of patients with advanced coronary artery disease. Metabolic tissue characterization represents the most specific definition of tissue viability currently available. However, the relatively high cost of the technology and the lack of reimbursement by major insurance carriers has limited widespread clinical application. In addition to the acceptance of PET as an advanced clinical imaging modality, this imaging modality excels as a sophisticated research tool assessing specific tissue functions that could not be visualized before in the living human heart. Without doubt, this technique will contribute significantly to the future characterization of pathophysiological alterations in substrate metabolism and other physiological processes such as autonomic innervation. Furthermore, the kinetics of radiolabeled cardiac drugs may be studied with PET to provide objective characterization of cardiovascular drug effects and thus enhance our understanding of pharmacokinetics in the human heart.

Coronary Disease↗