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PubMed2001

What if pediatric residents could bill for their outpatient services?

OBJECTIVE: We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics. METHODS: Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology. RESULTS: A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 +/- 0.01 and 0.81 +/- 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively. CONCLUSION: When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.

Accounting↗
PubMed1999

Use of the Decision Support System for VA cost-effectiveness research.

BACKGROUND: The Department of Veterans Affairs is adopting the Decision Support System (DSS), computer software and databases which include a cost-accounting system which determines the cost of health care products and patient encounters. OBJECTIVES: A system for providing cost data for cost-effectiveness analysis should be provide valid, detailed, and comprehensive data that can be aggregated. METHODS: The design of DSS is described and compared with those criteria. Utilization data from DSS was compared with other VA utilization data. Aggregate DSS cost data from 35 medical centers was compared with relative resource weights developed for the Medicare program. RESULTS: Data on hospital stays at 3 facilities found that 3.7% of the stays in DSS were not in the VA discharge database, whereas 7.6% of the stays in the discharge data were not in DSS. DSS reported between 68.8% and 97.1% of the outpatient encounters reported by six facilities in the ambulatory care data base. Relative weights for each Diagnosis Related Group based on DSS data from 35 VA facilities correlated with Medicare weights (correlation coefficient of .853). CONCLUSIONS: DSS will be useful for research if certain problems are overcome. It is difficult to distinguish long-term from acute hospital care. VA does not have a complete database of all inpatient procedures, so DSS has not assigned them a specific cost. The authority to access encounter-level DSS data needs to be centralized. Researchers can provide the feedback needed to improve DSS cost estimates. A comprehensive encounter-level extract would facilitate use of DSS for research.

Cost-Benefit Analysis↗
PubMedDate not supplied

Continuous quality improvement at work: the first team--Part I.

This first part of a two-part article describes the process of making the theory of continuous quality improvement a reality. The successes, the failures, and the struggles of the first team effort are outlined. The evolution of the team approach is captured from the perspectives of the quality directors, the facilitator, and the team leader. The team project discussed in this article focused on inpatient admissions and the assignment of patients to observation status.

Decision Making, Organizational↗
PubMed1997

An economic analysis of patients with active arterial peptic ulcer hemorrhage treated with endoscopic heater probe, injection sclerosis, or surgery in a prospective, randomized trial.

BACKGROUND: There are no published, detailed assessments of the direct costs of endoscopic hemostasis for actively bleeding peptic ulcers. We compared the direct costs of care for patients with active ulcer hemorrhage treated with endoscopic or medical-surgical therapies and correlated these costs with patient outcomes. METHODS: In a prospective, randomized, controlled trial, 31 patients with active ulcer hemorrhage at emergency endoscopy were randomly assigned to heater probe, injection, or medical-surgical treatment. For further ulcer bleeding, heater probe and injection patients were re-treated endoscopically and medical-surgical patients were referred for surgery. Direct costs were estimated using fixed and variable costs for resources consumed and Medicare reimbursement rates for physician fees. RESULTS: Compared to medical-surgical treatment, the heater probe and injection groups had significantly higher primary hemostasis rates (100% and 90% vs 8%) and lower rates of emergency surgery (0% and 10% vs 75%), blood transfusions, and median direct costs per patient ($4153 and $5247 vs $11,149). Furthermore, compared to medical-surgical treatment, the heater probe group had a significantly lower incidence of severe ulcer rebleeding (11% vs 75%). CONCLUSIONS: Heater probe and injection sclerosis are similarly efficacious treatments for active ulcer hemorrhage, and both treatments yield significantly lower direct costs of medical care and cost savings.

Aged↗
PubMedDate not supplied

Using physician work relative value units to profile surgical packages: methods and results for kidney transplant surgery.

BACKGROUND: This investigation outlines an approach for using the physician work relative value units (RVUs) in the Medicare Fee Schedule (MFS) to profile physician clinical activities. These techniques were then used to profile the physician services associated with kidney transplant patients at Emory University System of Health Care. METHODS: All physician services associated with 179 patients who had kidney transplant surgery in 1993 were studied. By using billing data, physician work RVUs were assigned to each service and the results were analyzed by type of service and the hospital department providing the service for physician work RVUs and physician charges. RESULTS: A mean of 130.4 physician work RVUs were involved in the 179 episodes of care. Surgical services represented 48.7% of the physician work activity in the kidney transplant. Visit and consultative services make up the next highest share with 25.5% of the physician work RVUs, whereas anesthesia makes up 13.3% of physician work RVUs. Physician charges totaled $16,249 for kidney transplants in 1993 dollars. Surgical services accounted for 54.2% of physician charges connected with kidney transplants, whereas visits and consultative services represented 20.6% of physician charges. CONCLUSIONS: Physician work RVUs in the MFS offer a unique and much needed perspective on physician clinical activities. Physician work RVUs are an important new tool for healthcare and researchers and their use needs to be more fully explored and benchmarks developed for all major medical and surgical services.

Fee Schedules↗
PubMed2001

Physician services in an academic neurology department: using the resource-based relative-value scale to examine physician activities.

The inability of physician managers and decision makers to critically analyze the resource utilization of physicians has hindered a more comprehensive understanding of the role of neurologists in the patterns and organization of medical practice. This article outlines an approach for using the physician work relative value units (RVUs) in the Medicare Fee Schedule (MFS) to address this problem and profile physician clinical activities in a comparative manner. These techniques are then used to profile the physician services associated with the neurology department at a large academic hospital. All 28,048 physician services associated with a neurology department in 1995 were studied. Using billing data, physician work RVUs were assigned to each service and the results analyzed by major services, type of service, and physician workload for physician work RVUs and physician charges. For the average service, mean physician charges were $187 per service while median physician charges were $120. Mean physician work RVUs per service averaged 1.3 RVUs, and the median was 0.94 per service. Of all the services provided in the neurology department, 65 percent are visits and consultations, while medicine services (e.g., nerve conduction studies, needle electromyography, neuropsychological testing, and electroencephalogram) make up 31 percent. All the other services combined represented less than five percent of the services in the department. The top five physicians in the department account for 33 percent of all physician work RVUs in the neurology department. Using the physician work relative values in the MFS provides a unique perspective for analyzing and understanding neurologists' work activities.

Academic Medical Centers↗
PubMed1986

Health services utilization in the U.S. population by health insurance coverage.

The goal of the National Medical Care Utilization and Expenditure Survey (NMCUES) is to improve the understanding of the ways in which Americans use and pay for health care. This report is one in a series of descriptive reports based on NMCUES data. Data concerning several aspects of insurance coverage were collected from household respondents in NMCUES. These data included the kind of insurance in effect for each person (Medicare, Medicaid, private, or other) and the use of inpatient and ambulatory health services. The purpose of this report is to provide descriptive information about the distribution of insurance coverage among the U.S. population and the use of inpatient and ambulatory services by people with different kinds of insurance. The results presented are based on data collected about the civilian noninstitutionalized persons in the NMCUES national household sample. In this report, "person-year" estimates for health insurance coverage are used; that is, individuals are assigned to different categories of insurance coverage according to the proportion of the year that they were covered by each kind of insurance. Although estimates are calculated as person-years of coverage, they are expressed as persons covered for convenience. Two important subpopulations--persons under 65 years of age and persons 65 years of age or over--are addressed separately because they have different patterns of insurance coverage and because utilization is so heavily influenced by age. Persons 65 years of age or over used significantly more inpatient and ambulatory services than persons under 65 years of age did. Only those in the younger group with Medicare, who were disabled, had utilization rates very similar to those of the aged. Persons under 65 years of age are classified by six mutually exclusive insurance categories: All Medicare. Medicaid, no private health insurance. Private health insurance, no Medicaid. Medicaid and private health insurance. Other coverage only. No insurance. Persons 65 years of age or over are classified by four mutually exclusive categories: Medicare only. Medicare and Medicaid. Medicare and private or other coverage. No Medicare. These categories of insurance coverage describe the kind of organization or program that supplies the coverage. With the exception of Medicare, which is a national program, these classifications provide little information about the scope of benefits and level of payment available to people who are covered. Considerable variation exists by State within the Medicaid category and by plan or program within the private insurance and other coverage categories.(ABSTRACT TRUNCATED AT 400 WORDS)

Age Factors↗
PubMed1997

Imaging project highlights timeliness issues.

University Health System Consortium, Oak Brook, IL, sought to identify the best practices of members in processing imaging reports. Internal benchmarking found best practices include: reading images before patient leaves department; requiring radiologists to read all assigned cases before leaving each day; coordinating transcriptionists' schedules with radiologists' dictation patterns; and providing remote access to edit and sign off on transcribed reports.

Benchmarking↗
PubMed1999

Effects of the Medicare Alzheimer's Disease Demonstration on nursing home entry.

STUDY QUESTION: Did the Medicare Alzheimer's Disease Demonstration, with its goal of improving caregiver outcomes through case management and subsidized community services, affect the nursing home entry rate of treatments with dementia compared to controls? DATA SOURCES: Interviews conducted at baseline and six months thereafter. Measures include date of nursing home entry, client and caregiver health, and income. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for an 80 percent discount on community care benefits, up to about $600 per month. DATA COLLECTION: All cases received baseline and semi-annual assessment interviews for up to three years after enrollment. Analyses are among cases that remained in the demonstration for more than 30 days after enrollment (n = 8,095). PRINCIPAL FINDINGS: The intervention of case management and subsidized community service had no effect on nursing home entry rates for treatments overall, compared to those of controls, and few effects on treatment subgroups, with the exception of one site where it may have increased nursing home entry rates. CONCLUSIONS: Providing case management and subsidized community services with the goal of improving caregiver outcomes may have little effect on nursing home entry rates for people with dementia.

Adult↗
PubMed1980

Health Care Financing Administration--Medicare and Medicaid; provider agreements: redesignation and rewrite of Medicare regulations; effective dates; effect of change in ownership. Final rule with comment period.

These regulations revise and redesignate the policies pertaining to provider agreements under the Medicare program to simplify them and to make them easier to read. We have made substantive changes only in the provisions relating to the effective date of the agreement and the effect of a change in ownership. These substantive changes were issued as proposed rulemaking on February 5, 1979, and will also apply to the Medicaid program. The substantive changes make provider agreements effective on the date of the onsite health and safety survey if all Federal requirements are met. If all requirements are not met, the effective date is the date the requirements are met or the date the provider submits an acceptable plan of correction or waiver request. The revised regulations also provide that existing provider agreements be assigned to new owners, subject to the terms and conditions under which they were originally issued. The intent of the substantive changes is to achieve maximum uniformity of policy for the two programs and to provide continuity of coverage for beneficiaries and recipients when there is change of ownership.

Health Facilities↗
PubMed1996

National survey of hospital-based pharmacokinetic services.

The status of pharmacokinetic services in the nation's hospitals was studied. A questionnaire was mailed in February 1995 to all 252 respondents to ASHP's 1994 national survey of hospital-based pharmaceutical services who indicated the provision of pharmacokinetic services in their institution. Ninety-eight completed questionnaires were returned (40.2% response rate). The pharmacokinetic services provided required an average of 19.1 person-hours per week, tended to be provided by staff pharmacists, were managed by the pharmacy department, tended to be most focused on aminoglycosides and vancomycin, required an average of 60 notes in patient charts per month, and relied on both computers and calculators for deriving values. There was little contact with patients during the consultation process. Drug concentration measurements tended to be scheduled by service providers, but confidence in the accuracy of the timing of dose administration and blood sampling was limited. Respondents believed that the services tended to be supported by other hospital personnel and that they were successful. There was very little expectation that the workload for providing pharmacokinetic services would increase in the near future. A national survey of hospital-based pharmacokinetic services showed that it took 19 hours per week on average to provide the services, that the focus was on aminoglycosides and vancomycin, and that the services were perceived to be supported by other departments.

Drug Monitoring↗
PubMed2001

Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture.

OBJECTIVE: While benzodiazepine treatment is known to increase the risk of hip fracture in older populations, controversy persists over which characteristics of benzodiazepine use (e.g., elimination half-life, dosage, duration of use) are most associated with such risks. METHOD: The authors reviewed the health care utilization data of 1,222 hip fracture patients and 4,888 comparison patients frequency matched on the basis of age and gender (all were at least 65 years old). Patients were enrolled in Medicare as well as in the New Jersey Medicaid or Pharmaceutical Assistance to the Aged and Disabled programs. Benzodiazepine use, as well as other covariates, were assessed before the index date (which was either the date of hospital admission for hip fracture surgical repair or, for the comparison subjects, a randomly assigned, frequency-matched date). RESULTS: All benzodiazepine doses > or =3 mg/day in diazepam equivalents significantly increased the adjusted risk of hip fracture by 50%. Significantly increased adjusted risks of hip fracture were seen during the initial 2 weeks of use (60% increase) and after more than 1 month of continuous use (80% increase) but not for 2-4 weeks of continuous use. Use of benzodiazepines other than long-acting agents significantly increased the risk of hip fracture by 50%. CONCLUSIONS: Even at modest doses, including some low doses currently advocated in prescribing guidelines for older patients, treatment with benzodiazepines appears to increase the risk of hip fracture. Patients appear to be particularly vulnerable immediately after initiating therapy and after more than 1 month of continuous use. Benzodiazepines with shorter half-lives appear to be no safer than longer half-life agents. Clinicians should be aware of these risks and weigh them against potential benefits when prescribing for elderly patients.

Aged↗
PubMed1994

Hospice for aged persons without cancer: the experience of the Hampshire County (MA) hospice.

Hospice is an option for patients with terminal illness of all types. The advent of the Medicare hospice benefit has led to a rise in numbers of hospice programs as well as hospice expenditure. Terminal care provided through hospice has a demonstrable cost advantage over conventional terminal care. This difference may dissipate as Medicare hospice expenditure continues to rise. An individual hospice program can define its mission within broad guidelines. A program electing to serve all terminally ill patients regardless of diagnosis can occasionally expect to be cast in the role of long term care-provider when six-month survival is exceeded. Precision in prediction of six-month survival would benefit patients and remove one major obstacle to participation by many primary care physicians. Prognostic techniques are being developed that, thus far, have proven no better than physician judgement in assigning risk or predicting survival. Hospice may provide a setting for clinical research of prognostication. The interdisciplinary team can facilitate hospice care and provide support to individual team members. Care of terminally ill non-cancer patients may require added human resources and alteration of team structure to cope with increased service needs and lengths of stay which may be likely to exceed those of cancer patients.

Aged↗
PubMed2005

Qualitative analysis of Medicare claims in the last 3 years of life: a pilot study.

OBJECTIVES: To study end-of-life care of a representative sample of older people using qualitative interpretation of administrative claims by clinicians and to explore whether this method yields insights into patient care, including continuity, errors, and cause of death. DESIGN: Random, stratified sampling of decedents and all their Medicare-covered healthcare claims in the 3 years before death from a 5% sample of elderly fee-for-service beneficiaries, condensation of all claims into a chronological clinical summary, and abstraction by two independent clinicians using a standardized form. SETTING: United States. PARTICIPANTS: One hundred Medicare fee-for-service older people without disability or end-stage renal disease entitlement who died in 1996 to 1999 and had at least 36 months of continuous Part A and Part B enrollment before death. MEASUREMENTS: Qualitative narrative of the patient's medical course; clinician assessment of care continuity and apparent medical errors; cause, trajectory, and place of death. RESULTS: The qualitative narratives developed by the independent abstracters were highly concordant. Clinicians felt that 75% of cases lacked continuity of care that could have improved the quality of life and the way the person died, and 13% of cases had a medical error identified by both abstracters. Abstracters disagreed about assignment of a single cause of death in 28% of cases, and abstracters and the computer algorithm disagreed in 43% of cases. CONCLUSION: Qualitative claims analysis illuminated many problems in the care of chronically ill older people at the end of life and suggested that traditional vital statistics assignation of a single cause of death may distort policy priorities. This novel approach to claims review is feasible and deserves further study.

Aged↗
PubMed1997

Rehabilitation costs: implications for prospective payment.

OBJECTIVE: To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care. DATA SOURCES/STUDY SETTING: Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states. STUDY DESIGN: For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible. DATA COLLECTION/EXTRACTION METHODS: Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained. PRINCIPAL FINDINGS: RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients. CONCLUSIONS: Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted.

Aged↗
PubMed1998

Defining teaching hospitals' GME strategy in response to new financial and market challenges.

The authors present an overview of current graduate medical education (GME) issues, particularly the financial challenges to teaching hospitals resulting from the Balanced Budget and Tax Payer Relief Acts of 1997 and other recent market-driven factors. They describe in detail the nature of Medicare GME payments before and after the 1997 legislation, with specific examples, and explain the negative financial impact of the legislation and aspects of the legislation that are designed to alleviate that impact. Other factors influencing GME program size and composition are also discussed, including oversupplies or shortages of physicians, the concern that teaching hospitals are using public funds to train international medical graduates, changing training requirements, etc. The authors also describe a recent consulting assignment during which they assisted a major teaching hospital to develop a GME strategy that was responsive to the organization's mission and patients and that took into account future GME financing challenges. Detailed explanations are given of how the consultants analyzed the hospital's GME programs and finances, developed and ranked key institution-specific program criteria (strategic, organizational and operational, and financial), and, in consultation with all key stakeholders, formulated a GME strategy specific to the institution's needs. The authors conclude by cautioning that each institution's GME strategy will be different, but that it is important for institutions to develop such strategies to better face future challenges.

Budgets↗
PubMed1980

Alternative approaches to physician reimbursement under medicare: a simulation.

A simulation approach was used to compare the effects of different methods of determining reasonable charges for physicians' services under Medicare on government outlays, physician revenues, and beneficiaries' financial burdens. This is an important policy area because of fee inflation and rises in physician income. Queens County claims for 1976 and 1977 were used for this analysis. The different methods that were compared to the current method, which is the 75h percentile of weighted customary charges adjusted for the Economic Index, included a single prevailing that dispensed with specialty groupings, an unadjusted prevailing eliminating the Economic Index correction, and average reasonable charges in a base year computed with and without regard for specialty board certification. The results of the trials showed that program costs are about 8 per cent higher without the Economic Index. The single prevailing cuts government costs but substantially raises beneficiaries' out-of-pocket costs. Patients not receiving assignment were most likely to have greater burdens. The average reasonable charge approach had little effect on any of the participants and does not justify the additional expense of the shift in computer programs. As a fee schedule approach would probably use single prevailing prices, the fact that socially undesirable results are generated is significant.

Fees, Medical↗
PubMed2000

The community assessment risk screen (CARS): identifying elderly persons at risk for hospitalization or emergency department visit.

OBJECTIVE: To develop and validate an instrument for identifying community dwelling elderly patients at increased risk for hospitalizations or emergency department (ED) encounters. STUDY DESIGN: Prospective cohort study. PATIENTS AND METHODS: The development cohort consisted of 411 Medicare fee-for-service patients and the validation cohort consisted of 1054 individuals enrolled in a Medicare Risk Demonstration. Baseline demographic, health status, and utilization measures were obtained from telephone interviews and mailed questionnaires. Service utilization data for the development cohort were obtained from Medicare claims files. Utilization and cost data for the validation cohort were obtained from submitted claims. RESULTS: Logistic regression identified 3 characteristics that were predictors of hospitalizations or ED visits during the following year in the development cohort: having 2 or more comorbidities, taking 5 or more prescription medications, and having had a hospitalization or ED encounter in the previous 12 months. A scoring system (range 0 to 9) was developed for each predictor variable and patients in the validation cohort were assigned to low (0 to 3) and high (4 to 9) risk categories. When compared with the low-risk group, the high-risk group was significantly (P < .01) more likely to be hospitalized (33% versus 14%), to have an ED visit (34% versus 15%), and to have higher per-member-per-month (PMPM) charges ($977 versus $445) during the following 12 months. CONCLUSION: The Community Assessment Risk Screen (CARS) is a simple instrument that can be used to identify elderly patients who are at higher risk for health service use and increased costs.

Aged↗