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PubMed1993

Financial impact of the Medicare Fee Schedule on a large multispecialty faculty practice in an academic medical center.

Although there have been preliminary studies of the financial impact of the Medicare Fee Schedule (MFS) on specialty-specific groups of practicing physicians in an academic setting, there has been no published report of the financial impact of the MFS on an entire multispecialty academic faculty practice. This 1992 study reports the estimated financial impact of the MFS on the faculty practice at the University of Michigan Medical School (UMMS). The authors calculated the difference between the Medicare payments to be received when the MFS is completely implemented in 1996 and the payments received in 1991, and then repeated this process for each year of the transition period, 1992-1996. The UMMS will experience a $1.2 million (-4.7%) loss under the fully implemented MFS. The medical departments project an 8% gain, while substantial losses are projected for the surgical departments (-10%) and hospital-based departments (-15%). Projections indicate that obstetrics-gynecology and ophthalmology will lose nearly 20% and that surgery will lose 9%. But large percentage gains are projected for neurology (+43%), physical medicine (+25%), and family practice (+17%). Analysis of the MFS transition's effects shows an abrupt and unpredictable financial impact in the first year. Faculty practice plans may be more disadvantaged under the MFS than other physician groups, yet the uncertain impact of the MFS in the first year (1992) may inhibit accurate financial planning for all physician groups.

Academic Medical Centers↗
PubMed1990

Setting up a fee for service program for psychiatric liaison nurses.

In the current health care climate, hospitals are under great pressure to find creative ways of preserving and generating revenue. As a result, all positions are routinely scrutinized for their value to the institution. Nurses have always been regarded as a major drain on the hospital's pocketbook, rather than as a revenue-generating resource. Because of their unique roles, liaison nurses provide many patient services which are third-party reimbursable. Practical guidelines for setting up a fee for service program are outlined together with the possible negative and positive repercussions of such a program. Enhanced job security and professional self-esteem may be offset by resistance from other disciplines and the possibility of a reduction in the volume of referrals. Although nurses who bill may face opposition from some groups, the ability to generate revenue is an important feature of this nursing role and is viewed as a strong asset by the institution.

Accounting↗
PubMedDate not supplied

A comparison of inpatient severity, average length of stay, and cost for traditional fee-for-service medicare and medicare HMOs in Florida.

This research compares the mean severity level, length of stay, and cost of Medicare health maintenance organization (HMO) and Medicare fee-for-service (FFS) inpatients. The results suggest Medicare HMOs have healthier inpatients and shorter lengths of stay, but more costly per-day utilization. These findings are contrary to the assumption that HMOs reduce daily utilization.

Acute Disease↗
PubMed1993

Fee setting in Canada: controversy and solutions.

No province in Canada has implemented an RVG, although both Alberta and British Columbia are in the final stages. Many complications exist. There is concern that those sections within the medical association that feel they will be financially disadvantaged will attempt to prevent the implementation of the RVG. They may persuade the board of directors not to implement or perhaps to phase in the implementation so that they have time to adjust to lower revenues. Even with simulations being done to establish the potential impact on sections, there is no model that can predict what behavioral changes may take place after the RVG is implemented. With the medical associations controlling the fee, governments must be assured that medical services will be delivered in the same manner in which they were delivered before the RVG and the global budget were instituted. An analysis of the changes and their causes is an important aspect of the process. Factoring out the relationships will be challenging.

Alberta↗
PubMed1995

Home health quality outcomes. Fee-for-service versus health maintenance organization enrollees.

Quality outcomes were compared between home health patients enrolled in the traditional Medicare fee-for-service (FFS) program versus a health maintenance organization (HMO) with a Medicare cost contract with the federal government. The quality outcome scores were similar between the two patient groups. However, other home health research showed superior quality outcomes for patients enrolled in the traditional Medicare FFS program versus an HMO with a risk contract with the federal government. Before signing contracts with HMOs, home health administrators will want to identify the type of Medicare contract the HMO has with the federal government.

Aged↗
PubMed1996

Home health resource utilization. Health maintenance organization versus fee-for-service subscribers.

A commonly held belief is that patients enrolled in health maintenance organizations (HMOs) are authorized fewer home health services than patients enrolled in fee-for-service (FFS) plans. This study compared home health resource utilization patterns between patients enrolled in a cost HMO and in FFS plans. Although no significant differences were found, the cost HMO subscribers actually received more services. Despite these similarities, home health administrators need to carefully craft contracts with cost HMOs.

Aged↗
PubMed1997

Home health nurse patient care and coordination time. Health maintenance organization versus fee-for-service.

Home health nurse visit and care coordination time were compared between Medicare patients enrolled in an health maintenance organization (HMO) and in the traditional Medicare fee-for-service program. In home nurse visit time did not differ for the two groups. Coordination time per episode of care was approximately 40 minutes longer for an HMO patient. When home health administrators develop discounted visit rates for HMO contracts, they must include the extra coordination time in the rates.

Aged↗
PubMed1978

Medical fee and service advertising: a response from physicians.

Restrictions on advertising about services performed by professional groups have recently been questioned by the government and consumerists. The purpose of this study was to determine physicians' attitudes about the use of advertising in their profession and also to compare these results with responses from dentists, attorneys, and accountants. While a survey of these groups in three metropolitan areas indicate mild support for advertising in general, there was a definite negative reaction to advertising in the respective professions. Participants also reported their attitudes about the effects of advertising on prices and fees, quality of services, and public expectation and governmental regulations. The concepts of social marketing and informative advertising are suggested as approaches that may meet the requirements of both the government and the professions.

Advertising↗
PubMed1984

Care of patients with colorectal cancer. A comparison of a health maintenance organization and fee-for-service practices.

The presence of a population-based cancer registry in a community with a health maintenance organization (HMO) enabled a detailed, longitudinal comparison to be made of care given for colorectal cancer in an HMO with traditional fee-for-services (FFS) care. An interview survey of 39 HMO and 150 FFS patients was supplemented with data from the cancer registry. Patients seen by the two provider groups were similar with respect to sociodemographic characteristics, severity of disease at diagnosis, and concurrent medical conditions. The HMO patients received more prediagnostic care but did not receive definitive surgical treatment as quickly as the FFS group. There were few differences in care, however, once diagnosis was made; there were no differences in access to care, rates of definitive surgery, chemotherapy, radiation therapy, length of hospitalization, number of follow-up physician visits, and most measures of satisfaction with care. No differences in outcome, including 4-year survival and 1-year health status, were found. HMO patients expressed significantly less concern about the cost of their care. These findings suggest an initial hesitancy to provide definitive care by the HMO but no significant differences in either the process or outcome of care once definitive care is begun.

Colonic Neoplasms↗
PubMed1989

Stage at diagnosis of breast cancer. Comparison in a fee-for-service and health maintenance organization practice.

This study assessed the effectiveness of two types of health plans in the diagnosis of female breast cancer by comparing the clinical stage at final diagnosis. Data on 202 cases diagnosed over a 4-year period from May 1983 to May 1987 were abstracted from medical records. Of these, 133 (65.8%) used fee-for-service (FFS) and 69 (34.2%) used health maintenance organization (HMO) plans. The two groups differed significantly on age and employment status; the HMO cases were younger than the FFS cases and were more likely to be employed. HMO cases also were more likely to have had some tests and procedures, but the test results were similar. Other demographic, risk factor, behavioral, clinical, and laboratory findings did not differ significantly by health plan, suggesting a uniformity of characteristics and of service availability. Overall, there was no difference between the groups in clinical stage of breast cancer at final diagnosis. On age-specific tests, however, the 45 to 55 year age group showed a significant difference in the stage of breast cancer at diagnosis with a higher proportion of HMO cases diagnosed at stage 1 than FFS cases. In contrast, in the 20 to 44 year age group, there was a nonsignificant trend for more FFS than HMO cases to be diagnosed at stage 1. Results from this study suggest that when offered by one medical practice, both FFS and HMO plans may be equally effective in the detection of breast cancer.

Adult↗
PubMed1990

High-cost patients in a fee-for-service medical plan. The case for earlier intervention.

This article describes the high-cost and very high-cost patients in the fee-for-service medical plan of one of the nation's largest banks in terms of their demographics and medical plan expenses and utilization, within a single year and during a period of 4 consecutive years. High-cost patients ($5,000-25,000 annually) were dominated by older persons and women 20 to 39 years, while the very high-cost patients (at least $25,000) tended to be older men and infants of both genders. Very high-cost patients used 5 to 7 times more hospital patient days and visited with a physician on an outpatient basis twice as often as high-cost patients. In turn, the high-cost patients experienced 37 to 50 times as many patient days and twice as many outpatient visits as patients whose annual expenses were below $5,000. Longitudinal analyses suggested that while most of the high-cost patients are typically low-cost patients or nonusers of services who experience high-cost time spans, some of them suffer from more serious chronic health problems and are apt to become very high-cost patients. Focusing case-management interventions on this small subgroup of high-cost patients may prevent some very high-cost cases in the future.

Adolescent↗
PubMed1998

Costs and outcomes of AIDS care: comparing a health maintenance organization with fee-for-service systems in the Boston Health Study.

OBJECTIVE: A 4-month observational cohort study was performed to compare the performance of one health maintenance organization (HMO) with two fee-for-service (FFS) systems in Boston, Massachusetts in treating 255 patients with AIDS. MAIN OUTCOME MEASURES: Total 4-month costs; cost subcomponents, including inpatient, outpatient, home care, and zidovudine costs; functional status (difficulties with activities of daily living); and satisfaction with care. RESULTS: Compared with FFS patients, HMO patients were better educated, more often white, less often on Medicaid, and more often reported homosexual or bisexual behaviors as HIV risk factors (all factors, p = .001). Both groups had similar duration of AIDS, baseline hemoglobin levels, and leukocyte counts. Total 4-month costs at the HMO were significantly lower than those in the FFS settings ($4799 U.S. versus $8540 U.S.; p = .013), as were outpatient costs ($1131 U.S. versus $1614 U.S.; p = .001), after adjustment for sociodemographic factors, baseline functioning, main HIV risk factor, and other clinical variables. Adjusted physical functioning (p = .32) and patient satisfaction (p = .82). were similar between systems. CONCLUSIONS: The HMO had significantly lower total costs without any observable decrement in functional outcomes or patient satisfaction. The largest component of these cost savings came from reduced spending on inpatient care, but the HMO also spent less on outpatient and home care. Better coordination of care at the HMO may have been responsible for these lower costs.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Incremental cost savings 6 months following initiation of insulin glargine in a Medicaid fee-for-service sample.

This study assessed the role of insulin glargine use on the short-term costs of diabetes care from a state Medicaid fee-for-service reimbursement perspective. A retrospective claims analysis was performed for 20% of Medicaid recipients in California (Medi-Cal) between November 2000 and September 2002. Each patient with continuous enrollment at least 6 months before and after the insulin glargine index date was matched with 2 reference patients by age, gender, diabetes diagnosis, and enrollment dates. Costs were calculated for emergency department, inpatient, outpatient, and pharmacy claims paid, and changes from baseline were determined. Incremental cost savings were estimated from baseline cost in the insulin glargine group multiplied by the difference in percentage of changes from baseline. Of the 1018 insulin glargine users, 267 satisfied inclusion criteria and were matched to 534 reference patients. Baseline treatment costs were 2.7-fold higher in the insulin glargine group. Absolute cost reductions in the insulin glargine and reference groups were 185 dollars and 72 dollars per patient, respectively. Incremental cost savings were 69 dollars per insulin glargine user, including more than 200 dollars in incremental savings for inpatient claims. Hypoglycemia decreased from 9.5% to 3.8% of inpatient claims in the insulin glargine group but remained 1.1% throughout in the reference group. Insulin glargine use was associated with reduced inpatient hypoglycemia-related claims paid and short-term reductions in the inpatient and total costs of diabetes-related care. Additional studies are warranted to assess the influence of insulin glargine on diabetes-related costs.

Adolescent↗
PubMed2005

Use of preventive services by Medicare fee-for-service beneficiaries: does spillover from managed care matter?

BACKGROUND: Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear. OBJECTIVE: We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA. RESEARCH DESIGN: This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources. SUBJECTS: We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study. MEASURES: We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL). RESULTS: Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13). CONCLUSIONS: From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.

Aged↗
PubMed2005

Evaluating the performance of medicare fee-for-service providers using the health outcomes survey: a comparison of two methods.

BACKGROUND: Health status measures are now being used for evaluating the performance of health care organizations. Trends in SF-36 component scores have previously been examined for Medicare-managed care plans but not for providers serving Medicare fee-for-service (FFS) beneficiaries. We compared 2 methods for evaluating the performance of Medicare FFS providers, the Research Triangle Institute (RTI) and Health Assessment Laboratory (HAL) methods. METHODS: Data were collected from 6547 Medicare FFS beneficiaries in 10 cohorts. SF-36 Physical Health (PCS) and Mental Health (MCS) component scores were computed at baseline and after a 2-year follow-up. The RTI approach predicts follow-up scores based on a standard care regression model. The HAL approach determines the percentage of beneficiaries whose status is the "same or better" at follow-up. Both approaches then compare observed to expected scores for each cohort. RESULTS: The HAL method did not detect any statistically significant differences for the PCS; the RTI method detected a small PCS difference for one cohort. The HAL method identified 4 cohorts that had significantly higher MCS scores; the RTI approach identified one cohort with significantly lower scores. CONCLUSIONS: The 2 approaches provided consistent assessments of provider performance for the PCS but not for the MCS. The differences in the MCS results may have been affected by differing treatment of deaths during follow-up. The HAL approach disregards deaths for the MCS, whereas the RTI method imputes values for death. Implications of using self-reported health status for monitoring provider performance are discussed.

Aged↗
PubMed2006

Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002.

BACKGROUND: Although studies have documented hospital and surgical service geographic variability, prescription use geographic variability is largely unknown. Opiate pain medications are widely used, particularly because the promulgation of clinical guidelines promoting aggressive pain treatment. This study describes temporal and interstate variability in aggregate prescription opiate medication use within U.S. Medicaid programs. METHODS: A dataset of 49 states' fee-for-service (FFS) Medicaid prescription drug dispensing records from 1996 to 2002 was compiled and used to quantify medication dispensing examining all opiates, controlled release oxycodone, and methadone. The defined daily dose (DDD) per 1000 FFS Medicaid adult enrollees per day was calculated for all opiate medication categories. A market basket of nonpain prescription medications was constructed for comparison. Rates, trends, and the coefficient of variation were determined overall, by year and for each state. RESULTS: From 1996 to 2002, overall use of opiate pain medications increased 309%. The market basket use increased 170%. Total opiate dispensing varied widely from state to state, with a range of 6.9 to 44.1 DDD/1000/d in 1996, and 7.1 to 165.0 DDD/1000/d (a 23-fold difference) in 2002. The coefficient of variation was 49.6 in 2002. Controlled release oxycodone and methadone had a greater rate of increase compared with all opiates. CONCLUSIONS: The dispensing of opiate medications in Medicaid programs increased at almost twice the rate of nonpain-related medications during the 7-year study period. Large, unexplained geographic variation in aggregate use exists. The impact of Medicaid cost-containment strategies on utilization and outcomes should be investigated.

Analgesics, Opioid↗
PubMed2003

Variations in patterns of care and outcomes after acute myocardial infarction for Medicare beneficiaries in fee-for-service and HMO settings.

OBJECTIVE: To assess revascularization and mortality after acute myocardial infarction (AMI) for all Medicare patients in fee-for-service (FFS) and health maintenance organization (HMO) settings in California. DATA SOURCES/STUDY SETTING: Hospital discharge abstract and death certificate data linked with Medicare enrollment files for patients aged 65 and over with Medicare coverage (69,040) discharged from a California-licensed hospital in 1994-1996. STUDY DESIGN: Risk-adjusted results were assessed for HMOs and FFS, as well as for FFS beneficiaries from areas served by each plan. DATA COLLECTION/EXTRACTION METHODS: Risk models were based on all sampled patients. The HMO patients were aggregated into 17 pseudoplans: 5 individual plans, 4 large plans split geographically (10 observations), and 2 "pseudoplans" of small HMOs. Observed versus expected 30-day mortality rates, lengths-of-stay (LOS) during the index hospitalization and any transfers, revascularization (coronary artery bypass graft [CABG] surgery and/or percutaneous transluminal coronary angioplasty [PTCA]) during the index hospitalization or 30 days after admission, were calculated for each pseudoplan. PRINCIPAL FINDINGS: Risk-adjusted death rate was slightly higher in FFS than in HMO settings (p < .01 with one risk adjustment model, n.s. with another). Three pseudoplans had significantly (p < .01) better than expected mortality rates. One pseudoplan was significantly worse (p < .05) with one risk adjustment model but not the other. The LOS and revascularization rates varied widely, but were not associated with outcomes. Plans with among the best results had the lowest LOS and revascularization rates. These pseudoplans were less likely to have their patients initially admitted to a hospital with revascularization capability, but the hospitals they used had higher CABG volumes. Even if CABG facilities were available during the index admission, in these plans with better than expected mortality rates, revascularization was often postponed or carried out elsewhere. CONCLUSIONS: For Medicare patients having an AMI in the mid-1990s in California, risk-adjusted outcomes were no different, or slightly better on average, for those in HMOs than in FFS. Not all plans performed equally well, so understanding what leads to differences in quality is more important than simple comparisons of HMOs versus FFS.

Aged↗
PubMed2001

Breast cancer outcomes among older women: HMO, fee-for-service, and delivery system comparisons.

OBJECTIVE: To analyze the relationship of health insurance status and delivery systems to breast cancer outcomes--stage at diagnosis, treatment selected, survival--focusing on comparisons among women aged 65 or more having Medicare alone, Medicare/Medicaid, or Medicare with group model HMO, non-group model HMO, or private fee-for-service (FFS) supplement. DESIGN: Retrospectively defined cohort from Sacramento, Calif, regional cancer registry. SETTING: Thirteen-county region in northern California with mature managed care market. PATIENTS: Female invasive breast cancer patients aged 65 or more (N = 1,146), diagnosed 1987-1993. MEASUREMENTS AND MAIN RESULTS: Health insurance was determined from hospital records. Outcomes were analyzed with multivariate regression models, controlling for age, ethnicity, time, and SES measures. Stage I diagnosis was more likely among group model HMO patients than among private FFS insured (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.84 to 2.40). Stage I tumors were significantly less likely for Medicaid patients (OR, 0.50; 95% CI, 0.31 to 0.82). Use of breast-conserving surgery plus radiation (BCS+) varied significantly by hospital type (including HMO-owned and various-sized community hospitals) and time. Survival of patients with private FFS, group-, and non-group model HMO insurance was not significantly different, but was for those with Medicaid or Medicare alone. CONCLUSIONS: This study sheds new light on the relationship of insurance to stage and survival among older breast cancer patients, highlighting the importance of distinguishing types of HMOs and types of FFS plans. These outcomes do not differ significantly between women with Medicare who are in HMOs and those with private FFS supplemental insurance. However, patients with Medicare/Medicaid or Medicare alone are at risk for poorer outcomes.

Aged↗