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At least 649 records · Page 36Linked to original sources
PubMed1998

The impact of reimbursement changes for intracoronary stents on providers and Medicare.

CONTEXT: New Medicare reimbursement policies will move stents into a different diagnosis-related group (DRG) than conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). OBJECTIVE: To examine the financial impact on hospitals and Medicare of these planned changes, taking into account costs, reimbursement, and the cost-offset effect of prevented complications. DESIGN: The economic impact of proposed reimbursement changes was modeled by using a retrospective clinical and economic data set from a single institution. PATIENTS AND METHODS: A total of 421 consecutive interventional cases from 1996 were examined by using actual cost data. The new, proposed revenues were assigned to these cases. From the hospitals' perspective, the focus was on contribution margin (the difference between revenues and costs), risk adjusted for case-mix severity. From Medicare's perspective, the focus was on expenditures. Various assumptions were adopted for two clinical variables: the effectiveness of stents in preventing the major PTCA-related complications of myocardial infarction and coronary artery bypass graft surgery and the relative proportions of myocardial infarction and coronary artery bypass graft surgery in the mix of complications. Under current Medicare DRG policies, coronary artery bypass graft surgery is highly profitable for hospitals, whereas myocardial infarction as a complication of PTCA has a negative financial impact. RESULTS: Under the new Medicare reimbursement policies, hospitals experience higher profitability with stents than with conventional PTCA under most assumed levels of clinical effectiveness and mixes of myocardial infarction and coronary artery bypass graft surgery. For Medicare, under most circumstances (including percentages of stent use and levels of clinical effectiveness that represent contemporary practice) stents lead to greater expenditures. CONCLUSIONS: Medicare reimbursement changes will substantially realign previously misaligned financial and clinical incentives for hospitals. The immediate effect on hospitals will be to enhance profitability, whereas the effect on Medicare will be to increase expenditures.

Angioplasty, Balloon, Coronary↗
PubMed2003

On the use of administrative databases to support planning activities: the case of the evaluation of neonatal case-mix in the Emilia-Romagna region using DRG and APR-DRG classification systems.

There are several versions of the Diagnosis Related Group (DRG) classification systems that are used for case-mix analysis, utilization review, prospective payment, and planning applications. The objective of this study was to assess the adequacy of two of these DRG systems--Medicare DRG and All Patient Refined DRG--to classify neonatal patients. The first part of the paper contains a descriptive analysis that outlines the major differences between the two systems in terms of classification logic and variables used in the assignment process. The second part examines the statistical performance of each system on the basis of the administrative data collected in all public hospitals of the Emilia-Romagna region relating to neonates discharged in 1997 and 1998. The Medicare DRG are less developed in terms of classification structure and yield a poorer statistical performance in terms of reduction in variance for length of stay. This is important because, for specific areas, a more refined system can prove useful at regional level to remove systematic biases in the measurement of case-mix due to the structural characteristics of the Medicare DRGs classification system.

Database Management Systems↗
PubMed2001

Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis.

BACKGROUND: A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease. METHODS: Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation. RESULTS: No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation. CONCLUSION: Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.

Aged↗
PubMed2001

Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial.

CONTEXT: Performance feedback and benchmarking, common tools for health care improvement, are rarely studied in randomized trials. Achievable Benchmarks of Care (ABCs) are standards of excellence attained by top performers in a peer group and are easily and reproducibly calculated from existing performance data. OBJECTIVE: To evaluate the effectiveness of using achievable benchmarks to enhance typical physician performance feedback and improve care. DESIGN: Group-randomized controlled trial conducted in December 1996, with follow-up through 1998. SETTING AND PARTICIPANTS: Seventy community physicians and 2978 fee-for-service Medicare patients with diabetes mellitus who were part of the Ambulatory Care Quality Improvement Project in Alabama. INTERVENTION: Physicians were randomly assigned to receive a multimodal improvement intervention, including chart review and physician-specific feedback (comparison group; n = 35) or an identical intervention plus achievable benchmark feedback (experimental group; n = 35). MAIN OUTCOME MEASURE: Preintervention (1994-1995) to postintervention (1997-1998) changes in the proportion of patients receiving influenza vaccination; foot examination; and each of 3 blood tests measuring glucose control, cholesterol level, and triglyceride level, compared between the 2 groups. RESULTS: The proportion of patients who received influenza vaccine improved from 40% to 58% in the experimental group (P<.001) vs from 40% to 46% in the comparison group (P =.02). Odds ratios (ORs) for patients of achievable benchmark physicians vs comparison physicians who received appropriate care after the intervention, adjusted for preintervention care and nesting of patients within physicians, were 1.57 (95% confidence interval [CI], 1.26-1.96) for influenza vaccination, 1.33 (95% CI, 1.05-1.69) for foot examination, and 1.33 (95% CI, 1.04-1.69) for long-term glucose control measurement. For serum cholesterol and triglycerides, the achievable benchmark effect was statistically significant only after additional adjustment for physician characteristics (OR, 1.40 [95% CI, 1.08-1.82] and OR, 1.40 [95% CI, 1.09-1.79], respectively). CONCLUSION: Use of achievable benchmarks significantly enhances the effectiveness of physician performance feedback in the setting of a multimodal quality improvement intervention.

Aged↗
PubMed2005

Cross-sectional age differences in personality among medicare patients aged 65 to 100.

1,084 older Medicare recipients were orally administered the NEO Five-Factor Inventory (NEO-FFI; P. T. Costa & R. R. McCrae, 1992). Participants were assigned to groups based on gender and age (65-79 or 80-100). An analysis of covariance showed that women had significantly higher Neuroticism, Openness, and Agreeableness scores; that older participants were significantly higher in Agreeableness; and that age differences in Agreeableness were significantly greater in men than in women. With the exception of Agreeableness, this study provides no evidence for age differences among those in the last decades of life.

Age Factors↗
PubMed1998

Patient response to marketing minimally invasive surgery for heartburn.

BACKGROUND: Over 40% of Americans suffer from "heartburn" at least once a month. This and other manifestations of gastroesophageal reflux (GERD) are often treated with neglect by both patients and their primary care physicians. Diagnostic evaluation is all too often sought only in late stages of the disease. We studied the response to a media campaign promoting minimally invasive surgery as a cure for longstanding heartburn. METHODS: The information was publicized on 14 TV and six radio stations over 4 weeks. Patients were referred to an 800-number and data on the following topics were obtained using a standardized questionnaire: demographics, reflux symptoms, previous specialist referral, diagnostic evaluation and treatment, insurance information, and reasons for and expectations in calling. All questionnaires were screened for likelihood of GERD (high, medium, low). A return call was placed to triage patients (surgical or medical appointment, information only, no contact). RESULTS: We received calls from 1,389 potential patients. Based on symptoms, medical therapy, and previous evaluation, 891 (64%) were judged to likely have GERD and assigned high-priority status. Of the patients providing insurance information, 32% were enrolled in an HMO; 29% commercial; 16% Medicare; 14% employer based; and 9% had no insurance. Six hundred ninety-eight high-priority patients were contacted. Of these, 402 (58%) wanted information only; 228 (33%) desired surgical and 68 (%) medical appointments. Two hundred fifteen patients (16% of callers) were seen by a surgical or medical consultant. One hundred thirty-five underwent diagnostic studies, of which 77 (57%) had pathologic esophageal acid exposure. Eighty-three patients have undergone surgery to date-60 laparoscopic and 14 open antireflux procedures; nine had other surgical procedures. CONCLUSIONS: Surprisingly, 64% of patients responding to a marketing campaign for heartburn have typical symptoms of GERD, have consulted one or more physicians and/or received medical treatment. More than half the patients tested (77/135) were found to have a positive 24-h pH study, and 78% (60/77) of these elected antireflux surgery to control their reflux symptoms.

Gastroesophageal Reflux↗
PubMed2002

Effectiveness of prompted voiding in treating urinary incontinence in cognitively impaired homebound older adults.

OBJECTIVE: The objective of this study was to examine the short-term effectiveness of prompted voiding (PV) in cognitively impaired homebound older adults. DESIGN: This was a prospective, controlled exploratory study with a cross-over design where usual care controls crossed-over to the intervention following an 8-week observation period. SETTING: Adults aged 60 years and older with urinary incontinence and who met Center for Medicare and Medicaid Services criteria for being homebound were referred to the study by home care nurses from 2 large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania. Nineteen cognitively impaired older adults were randomly assigned to either the PV intervention or a usual care attention control group. MEASURES: Measures used included structured continence and medical histories. Older American Research and Service Physical and Instrumental Activities of Daily Living scales, Folstein Mini Mental State Examination, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination. RESULTS: Nineteen subjects were randomly assigned to a PV (n = 9) or delayed attention-control group (n = 10). Treatment subjects with complete pretreatment and posttreatment data (n = 6) experienced a mean 60% reduction in daytime incontinent episodes compared with a mean 37% reduction among control subjects (n = 10). Following the control phase, subjects crossed over to the treatment protocol. A total of 15 subjects completed the PV protocol. Among all subjects completing the treatment protocol, there was a 22% reduction in daytime incontinent episodes compared with true baseline (immediately following the control phase for those crossing over from the control group). CONCLUSIONS: The PV intervention resulted in clinically significant reductions in urinary incontinence for many of the participants, which may be achievable for many cognitively impaired homebound older adults.

Aged↗
PubMed1984

How should Medicare pay physicians?

Medicare's system of paying physicians is criticized as being costly, inflationary , inefficient, inequitable , and confusing. Yet when alternative methods--to change practice arrangements, units of service, fee levels, and the assignment option--are examined, no one seems ideal. A fee-for-service system combined with a prospective payment schedule may offer the best compromise.

Capitation Fee↗
PubMed1987

Physician reimbursement: the environment for change.

Escalation of costs for physician care services in the Medicare program has elicited measures to rein in these expenditures. These include freeze and control of physician fees, limits on reimbursement for certain procedures, and mandated assignment of clinical laboratory service charges. An important step in rationalizing physician fees lies in the resource cost-based relative value study undertaken by the American Medical Association together with Harvard University economists. The results should redress inequities inherent in the current reimbursement system and allow a more suitable distribution of funds within the profession.

Evaluation Studies as Topic↗
PubMed1996

Understanding the financial implications of APGs (ambulatory patients groups).

The ambulatory patient group (APG) system, a new prospective payment system for reimbursing outpatient services, is being adopted by increasing numbers of third-party payers and may soon be used in the Federal Medicare program. APGs involve the grouping of healthcare services provided during a specified service period. Payment rates are complicated by the assigning of multiple APGs to a single patients encounter and by discounting schedules. APG cost management tools must be developed to assess the financial impact of this complex system.

Ambulatory Care↗
PubMed1998

Revised Medicare Policies for Support Surfaces: a review.

Support surfaces have been used for many years to treat or prevent pressure ulcers. In early 1996, the availability, application, and reimbursement for use of these products in the home care setting changed dramatically with the implementation of a new Medicare Part B "Medical Policy for Support Surfaces." This article reviews definitions and characteristics of the products as outlined in this policy, clinical criteria for patient qualification, and documentation requirements. Products assigned to Group 2 of the Medical Policy (those designed to treat patients with advanced stage wounds) are emphasized. Additional issues concerning billing, product selection based on patient need, environmental factors, and related financial implications are also presented.

Beds↗
PubMed1995

The effect of fixed payment on hospital costs.

New Medicare regulations have replaced the cost-based system of reimbursement of capital expenditures by hospitals with a fixed payment per case based on assigned diagnostic-related groups. For the first time, hospitals must pay the governmental share of their capital costs. At the same time, overall reform points toward more capitation or fixed payments from all payers. This article discusses possible responses to legislative and competitive reforms by hospital management and the resulting effectiveness of the changes. To identify the potential effect of capital payment reform, we highlight some of the key provisions and assumptions of the new regulations, discuss the management implications of a changed capital payment system, and explore alternative models of hospital investment behavior in a world where one price for services for all buyers is a probable scenario.

Budgets↗
PubMed1987

Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1988--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for the fiscal year beginning October 1, 1987. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier contract or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. In addition, this notice describes the methodology used for identifying contractors for competitive replacement under section 2326 of the Deficit Reduction Act of 1984.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1981

Protecting the personal funds of the mentally retarded: new federal regulations.

In July 1980 the federal government established new requirements for protecting the personal funds of residents of intermediate care facilities for the mentally retarded. The regulations grew out of dissatisfaction with state laws and with the Department of Health and Human Services' earlier regulations governing facilities receiving Medicare and Medicaid funds, and were a response to the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977. The new regulations give patients the choice of managing their own financial affairs, appointing a representative to manage them, or authorizing the facility to hold, safeguard, and account for their funds. Facilities' responsibilities include informing residents of their rights and obligations concerning their funds, keeping records of all transactions involving funds held for residents, allowing residents or representatives reasonable access to funds and records, keeping residents' and institutional monies separate, and using existing agencies such as public guardians' offices to address the cases of incompetent residents who lack representatives. HHS has assigned primary enforcement responsibility to state Medicaid agencies.

Financial Management↗
PubMed1994

Demonstration of the cost-effectiveness of a nurse practitioner/physician team in long-term care facilities.

To an HMO with a Medicare risk contract, providing high-quality medical care to a nursing home resident may generate considerable costs. To address this issue, Fallon initially assigned each primary care physician to just one nursing home. The program was successful in that coverage of all Fallon patients admitted to nursing homes was assured. In a pilot project 5 years ago, a geriatric nurse practitioner (GNP) was hired to provide primary and episodic visits to nursing home residents in three area nursing homes. Research was conducted to determine the effectiveness of a GNP-MD team. Based on positive outcomes, additional GNPs were recruited. In the current follow-up study, a review of the 1992 fiscal and utilization data for nursing home patients revealed significantly lower rates of emergency room transfers, hospital lengths of stay and specialty visits for patients covered by GNP-MD teams, as compared to patients covered by physician only. Nursing home drug costs, skilled nursing days and primary care visits were higher for patients covered by the teams, but the differences were not statistically significant. Overall costs were 42% lower for the aggregate pool (skilled nursing plus intermediate care) and 26% lower for those with long-term stays.

Aged↗
PubMed2005

BMI, physical activity, and health care utilization/costs among Medicare retirees.

OBJECTIVE: To examine the influence of physical activity (PA) and BMI on health care utilization and costs among Medicare retirees. RESEARCH METHODS AND PROCEDURES: This cross-sectional study was based on 42,520 Medicare retirees in a U.S.-wide manufacturing corporation who participated in indemnity/preferred provider and one health risk appraisal during the years 2001 and 2002. Participants were assigned into one of the three weight groups: normal weight, overweight, and obese. PA behavior was classified into three levels: sedentary (0 time/wk), moderately active (1 to 3 times/wk), and very active (4+ times/wk). RESULTS: Generalized linear models revealed that the moderately active retirees had US 1456 dollars, US 1731 dollars, and US 1177 dollars lower total health care charges than their sedentary counterparts in the normal-weight, overweight, and obese groups, respectively (p < 0.01). The very active retirees had US 1823 dollars, US 581 dollars, and US 1379 dollars lower costs than the moderately active retirees. Health care utilization and specific costs showed similar trends with PA levels for all BMI groups. The total health care charges were lower with higher PA level for all age groups (p < 0.01). DISCUSSION: Regular PA has strong dose-response effects on both health care utilization and costs for overweight/obese as well as normal-weight people. Promoting active lifestyle in this Medicare population, especially overweight and obese groups, could potentially improve their well-being and save a substantial amount of health care expenditures. Because those Medicare retirees are hard to reach in general, more creative approaches should be launched to address their needs and interests as well as help reduce the usage of health care system.

Age Factors↗
PubMed1990

Criteria and standards for evaluating intermediary and carrier performance--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning June 1, 1990. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary or carrier agreement or takes other contract actions; assigns or reassigns providers of services to an intermediary; or designates regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which requires us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

Centers for Medicare and Medicaid Services, U.S.↗