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PubMed2002

Motivating parents of kids with asthma to quit smoking: the PAQS project.

The Parents of Asthmatics Quit Smoking (PAQS) project contrasts two theory-based smoking cessation interventions for parents of children with asthma, and compares mechanisms of behavior change within and across theoretical perspectives. We hypothesize that enhancing the perception of risk to self and child will motivate smoking cessation more than standard approaches that emphasize building self-efficacy and coping skills for quitting in a population that is largely not motivated to quit smoking. Smokers (n = 288) and their asthmatic children who receive nurse-delivered in-home asthma education (as part of the insurance carrier's standard of care) are randomized into one of two treatment conditions: (1) the Behavioral Action Model (BAM), in which nurses emphasize goal setting and skill building to enhance self-efficacy to quit smoking, or 2) the Precaution Adoption Model (PAM), in which nurses tailor the intervention to the smoker's readiness to quit and incorporate biomarker feedback [i.e. level of carbon monoxide exposure to the smoker and level of environmental tobacco smoke (ETS) exposure to the child] in order to increase risk perception in smokers. In both conditions, smokers who are ready to quit receive the nicotine patch. Analyses will examine (1) quit rates, ETS level and motivation to quit as the primary dependent variables, (2) mediators of behavior change between and within conditions, and (3) relations between parent smoking outcomes and child asthma morbidity (i.e. ER visits and asthma symptoms) post-treatment. Results will help tailor interventions to this population, and identify mechanisms of behavior change that result in adaptive health outcomes for smokers and their children who have asthma.

Adolescent↗
PubMed2000

Academic health systems management: the rationale behind capitated contracts.

OBJECTIVE: To determine why hospitals enter into "capitated" contracts, which often generate accounting losses. The authors' hypothesis is that hospitals coordinate contracts to keep beds full and that in principal, capitated contracts reflect sound capacity management. SUMMARY BACKGROUND DATA: In high-overhead industries, different consumers pay different prices for similar services (e.g., full-fare vs. advanced-purchase plane tickets, full tuition vs. financial aid). Some consumers gain access by paying less than total cost. Hospitals, like other high-overhead business enterprises, must optimize the use of their capacity, amortizing overhead over as many patients as possible. This necessity for enhanced throughput forces hospitals and health systems to discount empty beds, sometimes to the point where they incur accounting losses serving some payors. METHODS: The authors analyzed the cost accounting system at their university teaching hospital to compare hospital and intensive care unit (ICU) lengths of stay (LOS), variable direct costs (VDC), overhead of capitated patients, and reimbursement versus other payors for all hospital discharges (n = 29,036) in fiscal year 1998. The data were analyzed by diagnosis-related groups (DRGs), length of stay (LOS), insurance carrier, proximity to hospital, and discharge disposition. Patients were then distinguished across payor categories based on their resource utilization, proximity to the hospital, DRG, LOS, and discharge status. RESULTS: The mean cost for capitated patients was $4,887, less than half of the mean cost of $10,394 for the entire hospitalized population. The mean capitated reimbursement was $928/day, exceeding the mean daily VDC of $616 but not the total cost of $1,445/day. Moreover, the mean total cost per patient day of treating a capitated patient was $400 less than the mean total cost per day for noncapitated patients. The hospital's capitated health maintenance organization (HMO) patients made up 16. 0% of the total admissions but only 9.4% of the total patient days. Both the mean LOS of 3.4 days and the mean ICU LOS of 0.3 days were significantly different from the overall values of 5.8 days and 1 day, respectively, for the noncapitated population. For patients classified with a DRG with complication who traveled from more than 60 miles away, the mean LOS was 10.7 days and the mean total cost was $21,658. This is in contrast to all patients who traveled greater than 60 miles, who had an LOS of 7.2 days and a mean total cost of $12,569. CONCLUSION: The capitated payor directed the bulk of its subscribers to one hospital (other payors transferred their sicker patients). This was reflected in the capitated group's lower costs and LOS. This stable stream of relatively low-acuity patients enhanced capacity utilization. For capitated patients, the hospital still benefits by recovering the incremental cost (VDC) of treating these patients, and only a portion of the assigned overhead. Thus, in the short run, capitated patients provide a positive economic benefit. Other payors' higher-acuity patients arrive more randomly, place greater strains on capacity, and generate higher overhead costs. This results in differential reimbursement to cover this incremental overhead. Having a portfolio of contracts allows the hospital to optimize capacity both in terms of patient flows and acuity. One risk of operating near capacity is that capitated patients could displace other higher-paying patients.

Capitation Fee↗
PubMed2004

Payment for procedural sedation.

PURPOSE OF REVIEW: As surgical procedures become less invasive and medical procedures become more invasive, the role of procedural sedation has become more important. The resulting proliferation of settings for procedural sedation and providers rendering sedation has brought attention to the economics of this service from nonanesthesia specialists and payers. Rapidly escalating expenditures for sedation have led to scrutiny from public and private insurance carriers. The review will summarize these trends and predict changes in coding and payment for procedural sedation. RECENT FINDINGS: Changes in coding for sedation by proceduralists have raised questions about the value of procedural sedation that have implications for anesthesiologists and other specialists administering sedatives for their own or others' procedures. The emerging literature on the role of registered nurses in administering new sedative agents has led to a re-examination of the role of anesthesiologists and other physicians in providing this care. Workforce projections demonstrating an ongoing shortage of anesthesia and nursing personnel have created a dilemma about the availability of professionals to meet the growing need for sedation. A proliferation of Medicare medical necessity rules may limit the availability of payment for monitored anesthesia care in many settings. SUMMARY: Coding, payment rules and fees for procedural sedation are likely to change in the coming 2-5 years. Those responsible for providing such services must consider the economic, clinical and workforce issues underlying these changes when planning to undertake or expand a commitment to sedation.

Journal Article↗
PubMed2005

Teaching professionalism within a community context: perspectives from a national demonstration project.

Most medical schools now include some component of professionalism in their curriculum, ranging from "white coat" ceremonies to didactic and small-group, case-based discussions. Often this format does not provide a context for the course content nor does it necessarily make the curricular themes relevant to population groups and communities most vulnerable to the inequities and injustices present in health care. The authors describe a community-based professionalism curriculum for preclinical and clinical year medical students and report evaluation data from three years (2001-2003) of this national demonstration project. The curriculum emphasized four themes: service, community, advocacy, and ethical behavior and was based on a service-learning pedagogy applied within community-based organizations. As part of the program evaluation, 95 students from 33 medical schools between the years 2001 and 2003 (response rate: 84.8%) completed an anonymous questionnaire. When asked what did they learn about professionalism that they did not learn (or expect to learn) in their medical school curriculum, the most common themes were (1) factors and influences affecting professional behavior, with many specifically citing pharmaceutical companies and insurance carriers (46.3%); (2) the role and importance of physician advocacy on behalf of their patients (37.9%); and (3) issues specific to the needs of vulnerable and disadvantaged populations (20.0%). This project demonstrates that community-based experiences can provide unique and relevant learning in a professionalism curriculum that can complement existing medical-school-based efforts.

Adult↗
PubMedDate not supplied

Profiles of functional recovery in fifty traumatically brain-injured patients after acute rehabilitation.

Research to demonstrate the efficacy of head injury rehabilitation is important at a time when cost-containment efforts are intensifying. A useful tool that would predict the functional improvement during hospitalization and length of stay (LOS) of persons with traumatic brain injury would be of benefit to patients and their families, insurance carriers, and rehabilitation specialists. This study examines functional improvements made by 50 traumatic brain-injured patients admitted to the rehabilitation unit at the University of California, Davis, Medical Center (UCDMC) as measured by the UCDMC Davis Functional Status Measure (DFSM), which was adapted from the Functional Independence Measure (FIM). The DFSM incorporates additional items to provide a more thorough measure of skills to be rehabilitated. The purpose of this study was to compare scores and profiles on the DFSM items obtained by patients with LOS greater than and less than and equal to the median rehabilitation LOS (23 days). Relationships were explored among admission DFSM scores, LOS for rehabilitation, discharge destination, and functional outcome. Results indicate that patients admitted to the rehabilitation unit attained a similar profile or level of function by discharge, regardless of admission Glasgow Coma Scale scores or admission DFSM scores. There were no significant differences in admission Glasgow Coma Scale score, age, acute LOS, or discharge disposition between the LOS groups. There was a significant difference in median admission DFSM score in 26 of 31 categories between the LOS groups. There was a significant difference in median DFSM change (admission to discharge) in 24 of 31 categories between the LOS groups. The admission DFSM total score was inversely proportional to the length of stay, with a correlation coefficient of 0.78. DFSM change and admission to discharge was linearly correlated with LOS (R = 0.66). The DFSM documents functional outcome and measures gains during inpatient rehabilitation. The DFSM profile is helpful in predicting the LOS needed to achieve those gains.

Activities of Daily Living↗
PubMed1994

Screening process to discover insured persons in need of rehabilitation.

In order to prevent early retirements in Germany, medical rehabilitation measures are implemented among workmen and salaried employees whose fitness for work is jeopardized or diminished. Only around half of those retiring early take advantage of these measures in the last 5 years prior to retirement. To increase the numbers making use of rehabilitation measures, we developed a screening process whereby the pension insurance institutions responsible for the measures are able to identify insured persons in need of rehabilitation and urge them to take part. The screening process comprises two stages: written questioning to determine the probable risk cases by means of predictors of early retirement, and medical clarification of these cases by means of a standardized rehabilitation assessment. The screening process and devices were tested in an experimental trial involving 600 people aged between 45 and 54 insured with a pension insurance institution responsible for workers in the Stuttgart area. Main results were: (1) The screening process was accepted by the insured. Around 70% of the insured took part in the screening. (2) The questionnaire is suitable for pre-selection of the probable risk cases that require medical clarification. Given complete answers, 83% of the cases were correctly classified in comparison with the judgement of the pension insurer's physicians. (3) The screening was effective, i.e. it increased the participation of insured persons in need of rehabilitation in rehabilitation measures. Compared with a control random sample, in the experimental trial, 70% more rehabilitation measures were applied for and approved.

Aged↗
PubMed1995

Factors influencing mode of claims settlement in workers' compensation cases.

This paper examines the variables that influence the means by which 10,192 injured workers settled their compensation claims during 1990. The data on which this study is based come from a state in Australia where there are three means by which workers' compensation claims can be settled by lump sum payment: settlement following a specific injury payment, early settlement payment and settlement following a common law payment. This paper is specifically concerned with identifying the variables that determine whether the claim will be settled by a lump sum payment and whether different modes of claims settlement by lump sum are unique and predictable from a range of variables that include injury characteristics and demographics. The results of logistic regression modelling revealed that those who received a lump sum settlement could be reliably distinguished from those who did not receive such a payment. Each mode of settlement varied in the extent to which it could be predicted. Contrary to expectations, the most difficult form of settlement mode to predict was that of specific injury payments (4% accurate) with the most predictive being early settlement payments (81% accurate). Common law payments were also highly predictable (48% accurate). The form of lump sum payment received by injured workers was found to depend on a range of injury characteristics, indices of severity and for common law payments, gender and potential income loss. It is argued that although injury characteristics play a part in the process of claims settlement, personal circumstances and insurance company policies are influential in dictating the form by which workers compensation cases are finalized.

Age Factors↗
PubMed1980

Are HMO enrollees being attracted by a liberal maternity benefit?

A study of recent birth patterns in the Southern California Region of the Kaiser-Permanente Medical Care Program (KPMCP) suggests that individuals may have been attracted to the Program by a liberal maternity benefit. The attraction is reflected in both the type of members joining KPMCP and the birth rate of those members. Although the KPMCP birth rate has been below that of the general population, new members in their first year of coverage delivered approximatey one third of all KPMCP births in 1977, twice the number of births that would be anticipated from an equal number of members in the plan for one year or more. The maternity copayment of up to $350 did not deter women already pregnant from joining KPMCP. Termination rates for new members who gave birth, however, were no higher than expected. The Pregnancy Disability Amendment of Title VII of the Civil Rights Act of 1964, which became effective April 29, 1979, may alter the maternity benefits offered by alternative insurance carriers. The law could impact KPMCP's enrollment and utilization of obstetric services.

Adolescent↗
PubMed1990

The effect of a second opinion program on hysterectomy performance.

Large regional variations in hysterectomy rates cannot be explained by gynecologic need alone, giving rise to concerns about unnecessary surgery. This study's population consists of women insured through a major insurance carrier in 1987 who were required to obtain a second opinion for an elective hysterectomy. Of the 1,698 women referred for a second opinion for a proposed hysterectomy, 135 (8.0%) were not confirmed for the surgery and a random sample of these women were selected for this study. While confirmation rates did not vary significantly among regions, surgical rates did. Women in the Northeast tended NOT to have surgery when not confirmed; women in the South and North Central regions who were not confirmed tended to have surgery. Among these women, some hysterectomies were performed for questionable reasons, i.e., symptoms did not warrant surgical intervention, no pathologic justification, or conservative treatment preferable.

Adolescent↗
PubMed1998

When courts review medical appropriateness.

OBJECTIVES: The authors examined how the courts have responded to public and private insurers' use of medical appropriateness criteria to establish coverage and payment policies. METHODS: A structured review of all federal and state court health insurance cases decided between 1960 and June 1994 that involved a dispute involving medical appropriateness was performed. A total of 3,215 published court decisions were analyzed, of which 203 met the criteria of relevance and 124 explicitly mentioned medical appropriateness criteria. The main outcome variable was whether the court ordered the insurer to provide coverage. RESULTS: In 185 cases, a definitive decision was rendered, and the insurer was required to pay in 57% of the decisions. Whether the insurer relied on an assessment or not, whether the assessment process was formal or informal, and who conducted the assessment did not appear to influence courts' decisions, nor did the specificity of the coverage exclusion. Significant predictors of courts ordering coverage were court jurisdiction, contract language assigning discretion to the insurer, severity of patient's condition, and whether the treatment appeared to work for the particular patient. CONCLUSIONS: For practice guidelines to be accepted by the courts, it is more important to focus on how insurance contracts are written than on how medical assessments are performed.

Eligibility Determination↗
PubMed2002

An approach that integrates patient education and informed consent in breast augmentation.

Informed consent requires surgeons to provide information about all available alternatives and their associated risks and tradeoffs to every prospective breast augmentation patient. The informed patient and surgeon then make decisions based on the information the patient has received, clinical parameters that may affect those decisions, and the patient's willingness to accept specific risks and tradeoffs. During the authors' 22 years of clinical practice, substantial changes have occurred in the requirements for adequate informed consent and the methods of ensuring that patients receive it. The numbers of alternatives for augmentation and the relative benefits and risks of each method have changed substantially over the past two decades. Four specific areas of postoperative issues stimulated major changes in the authors' approach to patient education and informed consent: 1) questions or dissatisfaction with implant size postoperatively, 2) questions about financial responsibility for costs associated with untoward events requiring reoperation postoperatively including capsular contracture or other problems, 3) spouses or other concerned parties rendering opinions postoperatively when they had not been involved in the informed consent process, and 4) criteria for whether reoperations were indicated, how many were indicated, and when implant removal without replacement might be most logical. This paper describes an approach that integrates patient education and informed consent in stages by 1) providing detailed, highly specific written and verbal information, 2) utilizing a staged approach to education and informed consent that provides information and requires simultaneous, informed consent in stages, 3) repeating each critical topic at least two or three times during the process, requiring repetitive written documentation by the patient on at least three different occasions, 4) emphasizing patient accountability for choices selected, and 5) organizing the education and informed consent process so that it is clinically practical and also increases thoroughness and documentation while conserving surgeon time. This staged, integrated system of patient education and informed consent uses a comprehensive set of informed consent documents that are available for downloading from the Plastic and Reconstructive Surgery Web site (www.plasreconsurg.org). Before incorporating any of the informed consent documents or statements reported in this paper, each surgeon should seek review by the surgeon's malpractice insurance carrier and by appropriate legal counsel to ensure compliance with state and federal laws applicable to the surgeon's practice. These documents have evolved to prospectively address patient management issues that have occurred over the authors' 22-year experience in augmentation. The documents are not endorsed by ASPS and do not necessarily represent the views of ASPS.

Breast Implantation↗