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PubMed2000

An economic analysis of an aggressive diagnostic strategy with single photon emission computed tomography myocardial perfusion imaging and early exercise stress testing in emergency department patients who present with chest pain but nondiagnostic electrocardiograms: results from a randomized trial.

STUDY OBJECTIVE: Conventional emergency department testing strategies for patients with chest pain often do not provide unequivocal diagnosis of acute coronary syndromes. This study was conducted to determine whether the routine use of single photon emission computed tomography (SPECT) imaging at rest and early exercise stress testing to assess intermediate-risk patients with chest pain and no ECG evidence of acute ischemia will lead to earlier discharges, more discriminate use of coronary angiography, and an overall reduction in average costs of care with no adverse clinical outcomes. METHODS: All patients in this study had technetium 99m tetrofosmin SPECT imaging at rest and were randomly assigned to either a conventional (results of the imaging test blinded to the physician) or perfusion imaging-guided (results of the imaging test unblinded to the physician) strategy. Patients in the conventional arm were treated at their physician's discretion. Patients in the perfusion imaging-guided arm were treated according to a predefined protocol based on SPECT imaging test results: coronary angiography after a positive scan result and exercise treadmill testing after a negative scan result. Study endpoints consisted of total in-hospital costs and length of stay. Hospital costs were calculated using hospital department-specific Medicare cost/charge ratios. Length of stay was calculated as total hospital room days billed (regular and intensive care). RESULTS: We enrolled 46 patients, 9 with acute myocardial infarctions. Patients randomly assigned to the perfusion imaging-guided arm had $1,843 (95% confidence interval [CI] $431 to $6,171) lower median in-hospital costs and 2.0-day (95% CI 1.0 to 3.0 days) shorter median lengths of stay but similar rates of in-hospital and 30-day follow up events as patients in the conventional arm. CONCLUSION: An ED chest pain diagnostic strategy incorporating acute resting (99m)Tc tetrofosmin SPECT imaging and early exercise stress testing may lead to reduced in-hospital costs and decreased length of stay for patients with acute chest pain and nondiagnostic ECGs.

Aged↗
PubMed2000

Emergency department use by the rural elderly.

This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration's National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.

Aged↗
PubMed1987

Medicare program; changes to the DRG classification system--HCFA. Final notice.

This final notice specifies certain changes in the Diagnosis-Related Group (DRG) classification system. It also lists diagnosis and procedures for which new or revised identifying codes (in the coding system of the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) on which DRG assignments are based) have been approved. This final notice also specifies the changes to the classification of alcohol and drug abuse DRGs and lists the revisions to the surgical hierarchies.

Alcoholism↗
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 October 1, 1990. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract 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.↗
PubMed1998

Satisfaction with outpatient geriatric evaluation and management (GEM).

The purpose of this study was to evaluate high-risk older adults' satisfaction with outpatient geriatric evaluation and management (GEM). Community-dwelling Medicare beneficiaries (n = 522) age 70 years and older who had a high probability of repeated admission to hospitals (Pra > .40) were randomly assigned to receive either usual care or GEM for six months. Despite the stresses imposed by outpatient GEM (e.g., new relationships with providers, frequent office visits and changes in treatments), the mean satisfaction scores of the recipients of GEM were 9% higher than those of the recipients of usual care (4.31 vs 3.96, p < .001). The primary physicians of GEM recipients were also highly satisfied with GEM care.

Aged↗
PubMed1986

AIDS: responding to the crisis. A public policy agenda.

Health care organizations must work toward public policy that addresses the cost of treating AIDS patients. One approach to the funding of AIDS medical care--although the evolving nature of the disease's treatment may make it difficult--would be to assign a diagnosis-related group weight to AIDS. Other possible mechanisms would be to establish AIDS as a covered medical benefit under Medicare or Medicaid. The agenda for public policy should include support of vaccine liability immunity for manufacturers of a potential AIDS vaccine and the allocation of funds for health worker education. It should oppose private insurance screening for the purpose of excluding from coverage individuals with AIDS or those who test positive to the AIDS virus. Health care organizations' efforts must include more than just lobbying in Washington, DC, however. Local business leaders and business coalitions also should be involved in the dialogue and in taking the first steps toward addressing the cost of care for AIDS patients.

Acquired Immunodeficiency Syndrome↗
PubMed1992

The role of the Medicare fiscal intermediary and the Regional Home Health Intermediary, Part 1.

The Medicare fiscal intermediaries (FIs) are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims. There are two primary functions for the FI--reimbursement review and medical coverage review. Hospital-based home health agencies relate to the hospital's FI for reimbursement purposes. All home health agencies are assigned to a special FI, the Regional Home Health Intermediary (RHHI), for medical review issues. The same or a different FI may audit the hospital's cost report. Freestanding home health agencies deal with separate reimbursement and medical review divisions within a single RHHI's office. The author reviews the role of the Medicare FI and the RHHI and their relationship to home health agencies. Part 2 will appear in the July/August issue.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1992

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1993--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 October 1, 1992. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (e.g., assigning or reassigning providers of services to an intermediary, designating regional or national intermediaries, etc.). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing 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.↗
PubMed1991

Medicare program; 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 October 1, 1991. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (e.g., assigning or reassigning providers of services to an intermediary; or designating regional or national intermediaries, etc.). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which require us to publish for public comment in the Federal Register whose criteria and standards against which we evaluate intermediaries and carriers.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1984

Medicare program; standards and criteria for evaluating intermediary and carrier performance during fiscal year 1985--HCFA. General notice with comment period.

This notice describes the standards and criteria to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for fiscal year 1985. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier agreement or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, as amended by section 2326 of the Deficit Reduction Act of 1984 (Pub. L. 98-369), 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.↗
PubMed1994

Factors affecting charity care and bad debt charges in Washington hospitals.

Uncompensated care has become a major issue in hospital finance as the number of uninsured persons has increased and hospital revenues have declined. Uncompensated care charges have two components--charity care and bad debt--that are distinct conceptually but often are commingled in hospital accounting practice. Data on charges assigned to charity care and bad debt in 1987 for 82 short-stay hospitals in Washington were merged with data from the 1987 Medicare Cost Report and AHA Annual Survey. The regression analyses performed indicate that the determinants of the percent of charges for charity care, bad debt, and total uncompensated care differ and suggest that bad debt should be isolated from charity care when estimating a hospital's level of effort in providing care to indigent patients.

Accounts Payable and Receivable↗
PubMed2000

Know difference between APC coding systems.

You'll need to revise your chargemasters to include all of the evaluation and management CPT codes for emergency and clinic technical services to prepare for the Health Care Financing Administration's switch to ambulatory payment classifications for outpatient services. Physician- and hospital-generated CPT codes present different challenges. Physician CPT coding should never be performed on the higher-level visits without complete documentation of the higher-level visits. A descriptive patient classification system (PCS) does not accurately portray the intensity of the visit, but the quantified PCS lists specific nursing tasks and assigns a point value to each one.

Abstracting and Indexing↗
PubMedDate not supplied

The role of the Medicare fiscal intermediary and the regional home health intermediary, Part 2.

The Medicare fiscal intermediaries (FIs) are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims. There are two primary functions of the FI--reimbursement review and medical coverage review. Hospital-based home health agencies relate to the hospital's FI for reimbursement purposes. All home health agencies are assigned to a special FI, the Regional Home Health Intermediary (RHHI), for medical review issues. This may be the same FI or a different one than that audits the hospital's cost report. Freestanding home health agencies deal with separate reimbursement and medical review divisions within a single RHHI's office. The author reviews the role of the Medicare FI and the RHHI and their relationship to home health agencies. Part 1 was featured in the June issue.

Costs and Cost Analysis↗
PubMed1994

Physician profiling. An analysis of inpatient practice patterns in Florida and Oregon.

BACKGROUND: Physician profiling is a method of cost control that focuses on patterns of care instead of on specific clinical decisions. It is one cost-control method that takes into account physicians' desire to curb the intrusion of administrative mechanisms into the clinical encounter. To provide a concrete example of profiling, we analyzed the inpatient practice patterns of physicians in Florida and Oregon. METHODS: Data for 1991 from Medicare's National Claims History File were used to profile 12,720 attending physicians in Florida and 2589 in Oregon. For each attending physician, we determined the total relative value of all physicians' services delivered during each patient's hospital stay. Relative value was measured in relative-value units (RVUs), according to the resource-based relative-value scale used by Medicare in determining payments to physicians. The mean number of RVUs per admission was then adjusted for the physician's case mix according to the patients' assigned diagnosis-related groups. The influence of the physician's specialty and of selected types of services (such as imaging and endoscopy) was also examined. RESULTS: Florida physicians used markedly more resources, on average, than their colleagues in Oregon (46 vs. 30 case-mix-adjusted RVUs per admission). The difference was apparent for all specialties and all types of service. To illustrate the profiling data potentially available to the medical staffs of individual hospitals, we examined specific data on individual attending physicians and for various types of service for three hospitals' staffs. Despite similar overall profiles that fell below the national mean, each staff had a different practice pattern and would require different efforts to improve efficiency. CONCLUSIONS: In an effort to encourage further debate, we have described one method of physician profiling. Profiling data help identify and characterize differences in practice style to which individual physicians or hospital staffs can respond. Because profiling is not based on rigid rules, it is a cost-containment strategy that can easily accommodate legitimate exceptions; it is therefore preferable to methods in which the appropriateness of each clinical decision is judged separately.

Cost Control↗
PubMed1999

Community care management across the continuum. Study results from a Medicare health maintenance plan.

A large national health plan piloting a community care management (CCM) model for its high-risk, chronically ill, Medicare population has demonstrated a significant reduction in overall medical costs for its participants. The key elements include: the proactive identification and risk stratification of members; assignment of advanced practice nurses to physicians with high-volume high-risk members; and ongoing clinical management across the continuum, establishing a continuous relationship with the member. The results are derived from a retrospective study comparing 6 months of claim data prior to the member entering CCM, with 6 months of claim data while participants received community, care management. Members in the pilot study experienced both a 42% reduction in institutional days and a 53% reduction in admissions to acute care settings. In addition, physician and specialists fees were reduced by 37%. This resulted in a 6-month net savings of $3,602 per participant. To be extremely conservative, the savings were reduced by 50% to reflect the possible impact of regression to the mean. Even accounting for this, the program's projected cost savings are $1,801 per participant in 6 months. The total projected savings for community care managed members in a fully implemented program divided by the entire enrolled population of 27,000 is $6.60 per member per month (PM/PM). The results of this study of care management across the continuum signal a new approach for medical management at a time when health care and the needs of the population are changing.

Case Management↗
PubMed1994

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1995--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 October 1, 1994. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (for example, assigning or reassigning providers of services to an intermediary or designating regional or national intermediaries). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

Financial Audit↗
PubMed2002

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2003 payment rates; and changes to payment suspension for unfiled cost reports. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2003. This rule also allows the Secretary to suspend Medicare payments "in whole or in part" if a provider fails to file a timely and acceptable cost report. In addition, this rule responds to public comments received on the November 2, 2001 interim final rule with comment period (66 FR 55850) that set forth the criteria the Secretary will use to establish new categories of medical devices eligible for transitional pass-through payment under the Medicare's hospital outpatient prospective payment system. Finally, this rule responds to public comments received on the August 9, 2002 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (67 FR 52092). CMS finds good cause to waive proposed rulemaking for the assignment of new codes to Ambulatory Payment Classifications and for the payment of influenza and pneumococcal vaccines under reasonable cost; justification for the waiver will follow in a subsequent Federal Register notice.

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