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Paying for the Medicare program.

Although the hospital insurance (HI) trust fund acted as a source of strength for the old-age, survivors, and disability insurance program during its recent financial crises, projections by HCFA and CBO reveal that the Medicare program will experience financing problems of its own within the next decade. No one would argue that Medicare's financing problems should be solved simply by raising more money. However, the prospect of insolvency in the HI trust fund and the increasing strain on general revenues from the Supplementary Medical Insurance trust fund require policymakers to survey the options for increasing Medicare revenues while cost-control devices are being developed. Indeed, even if cost-control efforts are completely successful, additional revenues may be needed in the future to finance new initiatives in the Medicare program. Therefore, this paper will look briefly at current efforts to regain control of soaring hospital and physician costs and then examine some of the more feasible options for increasing Medicare revenues.

Aged↗

Clinton, health care, and the crystal ball. With the Democrats back in power, where do we go from here?

Although Clinton's Health Security Act was unsuccessful, the President's first term did see considerable headway in health care policy, including the Health Insurance Reform Act, the Family and Medical leave Act, and improvements to both Medicare and Medicaid programs. Whether the result of a federal reform plan or free-market forces, efforts to control health care costs hinge on continued growth of managed care. Capitation is the wave of the future, according to some experts. America's aging population is rapidly overwhelming the Medicare Hospital Insurance Trust Fund. Clinton's balanced-budget proposal would keep Medicare solvent until 2006, while a bipartisan committee devises a long-term plan. Options for relief, however, are limited to increasing revenues by raising premiums and copayments or by decreasing spending.

Delivery of Health Care↗

Costing methodology in laparoscopic surgery.

This paper provides some basic insights in economic evaluation and costing methodology by means of illustrations in the field of laparoscopic surgery. Some general methodological aspects are discussed, as well as their impact on the calculation of both societal and hospital costs of medical interventions. First, Health Care Technology Assessment is described, and several techniques of economic evaluation in health care are situated in this area. Two fundamental concepts in costing analysis are discussed : opportunity costs and marginal (or incremental) analysis. Furthermore, it is argued that in designing an economic analysis, sufficient attention should be given to delineating the alternative treatment options and to determining the perspective from which the study is performed (patient, hospital, insurer, society,...). Subsequently, it is argued that all price and wage data for activities performed within a certain period should apply to the same time period. Finally, in order to facilitate overview, re-calculation and interpretation of cost data, it is advised to distinguish fixed from variable costs. Different categories of societal costs are described, as well as a number of methodologies for their evaluation. In calculating hospital costs, the costs of all different resources used (e.g. buildings, equipment, staff, materials) must be identified precisely. The issues of annuitising initial investment expenses, calculating operating and maintenance costs, and allocating labour and overhead costs are discussed. Finally, it is argued that, in all studies, it should be investigated whether the results of the economic analysis are robust to the models' assumptions, by means of sensitivity analysis. This paper provides a practical toolkit for medical doctors, to allow a correct understanding and critical analysis of economic literature in the field of laparoscopic surgery.

Cost-Benefit Analysis↗

Manage indirect practice expense the way you practice medicine: with information.

PURPOSE: Surgeons are increasingly faced with the pressures of maintaining the highest quality of patient care, while at the same time maintaining financial viability. The purpose of this project was to provide a framework for analyzing practice costs for colorectal surgeons using an activity-based cost accounting model. METHODS: A survey of 11 practices that were diverse in terms of geography, managed care penetration, academic vs. private practice style, and case distribution was performed. In activity-based costing the assignment of typical costs such as staff salaries are assigned to the appropriate business process. The business processes employed in this study were service patients in the office, perform in-office procedures, schedule cases in facilities, service patients in the hospital, insurance authorization, maintain medical records, billing, collections, resolve billing disputes, interaction with third parties, maintain professional education, sustain and manage the practice, maintain the facility, teaching and research, and performing drug studies. The final step is to assign the cost associated with all appropriate business processes to the appropriate cost object. The cost objects in this study were defined as a charge office visit, no-charge office visit, charge hospital visit, in-office procedures, in-facility procedures, and performing drug studies. The data were then analyzed to allow a comparison of four similar practices within the study group. RESULTS: The data demonstrated that the cost of seeing a charge office visit ranged from $55 to $105. Similarly, the cost of seeing a no-charge office visit during the global period ranged from $43 to $100. The study analyzed possible explanations for the wide variability in these costs. CONCLUSIONS: It is essential that physicians clearly understand the sources of expenses generated by the operation of their practices. A clear comprehension of costs will lead colorectal surgeons to make appropriate decisions regarding such important issues as office staffing ratios, office square footage, and instrumentation acquisitions.

Colorectal Surgery↗

Actuarial status of the Social Security and Medicare programs.

The Boards of Trustees for the two Social Security and the two Medicare Trust Funds recently released their annual reports to Congress detailing the operations of the trust funds during 1991 and their projected financial status for future years. Based on the Trustees' best estimates, the reports show: The Federal Old-Age and Survivors Insurance (OASI) Trust Fund will be able to pay benefits for about 50 years. Congress will eventually need to take action to assure the long-range financing of the program. The Federal Disability Insurance (DI) Trust Fund will be able to pay benefits for only about 5 years and is not adequately financed. As a result, the Board is required to make a separate report to the Congress on the unfavorable financial condition of this trust fund. The Board urges that prompt legislative action be taken to improve the financial integrity of the trust fund, after a review of the disability program. The Federal Hospital Insurance (HI) Trust Fund will be able to pay benefits for only about 10 years and is severely out of financial balance in the long-range. The Trustees urge the Congress to take additional actions designed to control HI program costs either through specific program legislation or as a part of enacting comprehensive health care reform. The Federal Supplementary Medical Insurance (SMI) Trust Fund is financed on a year-by-year basis and, on this limited basis, is adequately financed. The Trustees urge the Congress to take additional actions designed to control SMI costs either through specific program legislation or as part of enacting more comprehensive health care reform.

Budgets↗

Personal privacy in the health care system: employer-sponsored insurance, managed care, and integrated delivery systems.

Widespread collection and use of identifiable information can promote social goods while, at the same time, infringing on personal privacy. Information systems are developing within the context of a fundamental transformation in the organization, delivery, and financing of health care. Changes in the health care system include rapid development of employer-sponsored health coverage, managed care organizations, and integrated delivery systems. These complex, multifaceted arrangements for delivering and paying for health care require ever-more-sophisticated information systems that facilitate extensive sharing of personal data. Systemic flows of sensitive health information occur both vertically and horizontally among employers, hospitals, insurers, laboratories, and suppliers. Beyond this complex web of vertical and horizontal sharing are the multiple demands for information management, quality assurance, research, governmental regulation, and public health. Theoretical problems exist with the law and ethics of informational privacy. The traditional method of exercising control over personal health information is through informed consent. Informed consent, however, within a modern health information infrastructure becomes highly complex. In this kind of environment, the doctrine of informed consent is flawed and does not provide sufficient control over personal information to assure adequate protection of privacy.

Biomedical Research↗

[Health care reform and management models].

This article tries to indicate the direction of progress in management being taken in health sector reforms in Latin America. The piece first discusses the tension between local forces and international neoliberal trends being manifested in the reform in various countries. The article next looks at the distinction between the tools and the management models that are being applied, presenting a taxonomy of three management levels: macromanagement (national health systems), midlevel management (hospitals, insurers, and other such institutions) and micromanagement (clinics). The piece concludes by reflecting on the future of management in the health sector in Latin America, where health systems are overadministered and undermanaged. Their future depends on multiple factors, most of which are outside the health care field itself. Better management of policies, institutions, and patients would be a tremendous tool in directing the future. Management is here to stay, with greater emphasis on either supply--hospitals and physicians--or demand--citizens or clients. For both the public and private sectors, health management is central to health sector reforms in Latin America.

Health Care Reform↗

Omnibus Reconciliation Act of 1981: legislative history and summary of OASDI and Medicare provisions.

In this article, the Commissioner of Social Security traces the legislative development and summarizes the final form of changes in the Old-Age, Survivors, and Disability Insurance (OASDI) and Medicare programs incorporated in the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35). This legislation, signed into law by President Reagan on August 13, contains a major portion of his Program for Economic Recovery, announced to the Nation in February. The final section of the article shows that, although the Social Security and Medicare provisions in Public Law 97-35 will have a favorable effect on the overall financial status of the OASDI and Hospital Insurance Trust Funds, these changes will not be sufficient to restore the financial soundness of the programs in the near term or over the long range.

Aged↗

Health Care Value Is the Next Challenge to Medicine

Health care value is the analysis of clinical outcome compared with the use of resources for a clinical condition. With any of a number of tools, payers, hospitals, insurance companies, health maintenance organizations (HMOs), and physician groups can assess the quality of the care that has been purchased or delivered. Crude measurements derived from UB-92 or HCFA databases may not reflect the complexity of care. Chart analyses in the inpatient setting may not link an outcome to the outpatient setting. We use an open architecture database compatible with several methods of data entry to establish health care value by physician-determined clinical indicators for quality of care. This allows physicians, vendors, hospital systems, HMOs, and payers to evaluate numerous variables across the continuum of health care in a proactive physician-centered environment. Current programs are in development for the specialties of obstetrics and gynecology, cardiology, urology, gastroenterology, oncology, and orthopedics for implementation in 11 cities across the United States.

Journal Article↗

Actuarial status of the old-age and survivors insurance and disability insurance trust funds.

The 1982 Annual Report of the Board of Trustees of the Old-Age and Survivors Insurance (OASI) and Disability Insurance (DI) Trust Funds indicates sever financial problems in both the short and the long range. The short-range financial status is significantly worse than was estimated last year, after enactment of the 1981 legislation, because of continuing unfavorable economic conditions. The estimated long-range deficit is the same as the deficit that was estimated last year before the 1981 legislation and is therefore somewhat worse than was estimated immediately after enactment of the legislation. Under present law, which authorizes temporary interfund borrowing amount the OASI, DI, and Hospital Insurance (HI) Trust Funds, the OASI Trust Fund would become unable to pay benefits on time by July 1983. The assets of the DI Trust Fund, on the other hand, are expected to grow rapidly in both the short and long range. If the assets of both the OASI and DI Trust Funds were combined, however, the two funds would still become unable to pay benefits on time by the latter half of 1983, based on all four sets of economic and demographic assumptions in the 1982 report. Even if the temporary interfund borrowing authority in present law were extended, the combined assets of the OASI, DI, and HI Trust Funds would become insufficient to pay benefits on time by 1984, based on the two less favorable sets of assumptions in the 1982 report. Based on the other two, more favorable, sets of assumptions, the three combined funds could pay benefits on time through the 1980's but there would be little or no margin of safety to permit timely payment of benefits if economic conditions are even slightly less favorable.

Costs and Cost Analysis↗

The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment.

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.

Adult↗

Gender differences in practice patterns of Ontario family physicians (McMaster medical graduates).

This study examined the extent to which physician gender influences practice patterns. Data came from the Ontario Hospital Insurance Plan billing profiles of general practitioner and family medicine graduates of McMaster University School of Medicine. The women physicians studied were more likely to be certified in family medicine than the men and a higher proportion of their patients were female. Women were more likely to be working part time, billed during fewer months of the year, earned less, and saw fewer patients. They provided greater numbers of services in psychotherapy and counselling and ordered more laboratory tests; associated with this were higher costs per service and per patient. Women offered a less diverse mix of services than men. They provided fewer hospital, emergency room, and intrapartum services and a lower proportion of women included house calls, after-hours work, hospital, emergency room, surgical or intrapartum services in their service mix. Thus these women appeared more likely to restrict their practices to the office setting and to provide a higher proportion of psychosocial care. The overall impact of these sex differences in practice patterns on the health care system requires further exploration.

Family Practice↗

The effectiveness of a regulatory strategy in containing hospital costs. The Ontario experience, 1967-1981.

This study documents the increases in real inputs (e.g., labor and equipment) employed in Ontario's hospital sector between 1968 and 1981--a period of universal government-financed hospital insurance and a government regulatory strategy involving global budgeting. Total expenditures in Ontario increased by only 16 per cent in terms of real inputs, as compared with an increase of 101 per cent in the United States. Real inputs per patient-day increased at a mean annual rate of 0.68 per cent in Ontario versus 5.19 per cent in the United States (P less than 0.001). Real inputs per admission decreased at a mean annual rate of 1.12 per cent in Ontario, as compared with an increase of 4.15 per cent in the United States (P less than 0.0001). We conclude that regulation can contain the growth of real inputs employed in the hospital sector even in the face of an incentive structure that does not promote cost consciousness on the part of patients or physicians. Although the effect of this strategy on the quality of care is unknown, so far it appears to have been politically acceptable in Ontario.

Budgets↗

A large private university hospital system. The Johns Hopkins Oncology Center.

Clinical trials are a major commitment for a university-based comprehensive cancer center. In 1992, The Johns Hopkins Hospital registered 3508 new patients with cancer and, from this large population, 2880 patients were entered in clinical trials (many patients participated in more than one protocol). The Oncology Center, one of many departments at Johns Hopkins that conducts clinical research, participates in phase I and II new drug trials, phase III comparative studies, and, increasingly, in epidemiologic and prevention research. This calls for much broader participation by community hospitals and for many more patients who normally would not come to Johns Hopkins for their care. There are more than 100 protocols available from the Eastern Cooperative Oncology Group, but Johns Hopkins may participate in no more than 20 at any given time. Thus, every research facility must be selective about the trials in which it participates, given the finite number of hours, dollars, and resources available to carry out these programs. The institution provides safeguards to protect the interest of the patient. These include review and annual overseeing of the concept, design, and specifics of the proposed study. The pharmacy and nursing staff play an important role in control of chemotherapy distribution and use. Patients and physicians, however, must understand the questions the study is asking and agree that they are worth answering. There are problems in motivation; information; costs to the patient, hospital, insurers, and the physician; the concept of the placebo; and informed consent. Clinical research is the most ethical way to test drugs, radiation therapy, surgical procedures, or other new treatments. The clinical trial must meet rigorous criteria of design, conduct, and analysis. The patient must understand the issues and be a volunteer. We must make every effort to help patients and physicians get information about clinical trials and to participate if they choose.

Baltimore↗

Health care and the elderly.

America's health care crisis is hitting our elderly and threatens to cripple Medicare, the elderly's financial support system. Medicare was designed to ensure that every elderly American would be protected against the destruction of life savings as a result of illness. Elderly Americans would be able to enjoy their golden years without the financial burden of medical bills. Today, this vision is almost extinct. Medicare has been placed on the endangered species list. Market predictions indicate that Medicare's Hospital insurance Trust Fund will be depleted by 1988 if current trends continue. The elderly presently must pay on the average about 14% of their health care bill. In addition, Medicare pays little for long-term care; and about 45% of long-term care is paid for out-of-pocket by the elderly and their families. Alternative approaches are desperately needed of Medicare if our elderly are to survive.

Aged↗

Primary total knee arthroplasty in patients receiving workers' compensation benefits.

OBJECTIVE: To determine the influence of Ontario Workplace Safety and Insurance Board (WSIB) benefits on short-term clinical outcomes of primary unilateral total knee arthroplasty (TKA). METHODS: In a retrospective matched-cohort study at a single tertiary-care arthroplasty centre in Ontario, we compared a study cohort of 38 successive primary TKA patients receiving WSIB benefits from 1998 to 2002 to 38 controls, a matched cohort of non-WSIB patients, comparing Oxford Knee Score and Knee Society Score (both clinical and functional components) as well as flexion and pain variables, preoperatively and at postoperative intervals of 6 weeks, 6 months and 1 year. At least 1 year after their surgery, all patients were asked to complete a non-validated patient satisfaction survey. The number of clinic visits related to the operation was also compared, by means of Ontario Hospital Insurance Plan billing codes for each individual. RESULTS: Preoperative measurements showed the 2 groups to be similar. At follow-up, WSIB patients had significantly higher pain scores, poorer self-perceived functional outcomes and a lower range of knee flexion than the control group. WSIB patients also required more postoperative clinic visits and were more reluctant to answer questions about functional outcome. CONCLUSIONS: Short-term outcomes of primary TKA in patients receiving WSIB benefits are inferior to those of non-WSIB patients. WSIB patients are seen more frequently for postoperative follow-up, which we would attribute to the persistence of subjective complaints after TKA.

Aged↗

Medico-economic implications of industrial hand injuries in India.

625 five consecutive cases of industrial hand injuries attending the Employee's State Insurance Hospital, Jaipur, have been studied from 1983 to October 1986. The incidence of injuries was 36 per 10,000 workers per year. 47% were due to entrapment of the hand in active machines, 25% occurred during lifting and transportation of heavy objects and 12% while handling tools. The injuries resulted in residual deficit in 55% of cases and were serious enough to require absence from work of more than four weeks in 48% of cases. On an average 35 days were lost per injured worker. The average economic loss per injured worker was Rs. 6900 (approximately pounds 275) for workers in the wage-range of Rs. 5400 to 19,200 (pounds 216 to pounds 768) per annum.

Accidents, Occupational↗