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PubMed1994

Coding and reimbursement issues for dual-energy X-ray absorptiometry.

Bone densitometry has a unique and invaluable place in the prevention, diagnosis, and management of osteoporosis. Dual-energy X-ray absorptiometry (DEXA) is currently considered the bone densitometric technique of choice. With this method, the patient at risk for osteoporosis can be identified so that appropriate clinical interventions to prevent fracture can be undertaken. DEXA also allows assessment of the efficacy of these interventions in preventing bone loss. As with any other technology, however, bone densitometry must be properly used in the clinical setting to achieve this benefit. Critical to the proper use of the technology is the realization that a complete assessment of fracture risk requires the measurement of both the spine and the proximal part of the femur, not either site alone, and that assessment of therapeutic efficacy might also require the measurement of both sites, not either site alone. Effective January 1, 1994, the Clinical Procedural Terminology (CPT) code for DEXA has been 76075. This code is intended for measurement of a single site and is to be reimbursed at a global rate of $60.85. Although the assignment of a CPT code for this clinically valuable technology is most welcome, the lack of a code reflecting at least two sites of study and the low rate of reimbursement for a single site suggest a misunderstanding of the actual costs of the technology and the need, on occasion, for measurements at multiple sites.

Absorptiometry, Photon↗
PubMed1997

Health Care Financing Administration/American Society for Cytotechnology inspections: government assessment of cytology laboratory practice under the regulations of the Clinical Laboratory Improvement Amendments of 1988.

Since 1988, the American Society for Cytotechnology has performed inspections of 206 cytology laboratories in the United States under contract to the Health Care Financing Administration. These surveys are conducted by a team of supervisory-qualified cytotechnologists, including a specially trained survey team leader. A board-certified anatomic pathologist is assigned to each team and is on call for each survey. Laboratories are assessed for compliance with the regulations of the Clinical Laboratory Improvement Amendments of 1988 and, in particular, the area of quality control in cytology. These surveys are unique in that a sample of at least 0.1% of a laboratory's annual case volume is reevaluated by the survey team. Of the 206 laboratories surveyed, 116 were found to be in substantial compliance with the regulations while 90 were found to have Condition level deficiencies. Of those with Condition level deficiencies, 8 have had their Clinical Laboratory Improvement Amendments of 1988 certificates limited for cytology, and 16 have been terminated from Medicare participation.

Accreditation↗
PubMed2007

Sensitivity of the hazard ratio to nonignorable treatment assignment in an observational study.

In non-randomized studies, estimation of treatment effects generally requires adjustment for imbalances in observed covariates. One such method, based on the propensity score, is useful in many applications but may be biased when the assumption of strongly ignorable treatment assignment is violated. Because it is not possible to evaluate this assumption from the data, it is advisable to assess the sensitivity of conclusions to violations of strong ignorability. Lin et al. (Biomet. 1998; 54:948-963) have implemented this idea by investigating how an unmeasured covariate may affect the conclusions of an observational study. We extend their method to assess sensitivity of the treatment hazard ratio to hidden bias under a range of covariate distributions. We derive simple formulas for approximating the true from the apparent treatment hazard ratio estimated under a specific survival model, and assess the validity of these formulas in simulation studies. We demonstrate the method in an analysis of SEER-Medicare data on the effects of chemotherapy in elderly colon cancer patients.

Aged↗
PubMed2000

Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study.

OBJECTIVE: To determine the causes of blindness and visual impairment in a population-based sample of older Americans. METHODS: A random sample of 3821 residents of Salisbury, Md, between the ages of 65 and 84 years was identified from Medicare records. Sixty-six percent (2520 persons) agreed to undergo an eye examination; 26% of the participants were African American. The clinical examination included acuity testing with an Early Treatment Diabetic Retinopathy Study chart and standardized refraction testing for those with a visual acuity worse than 20/30, slitlamp and dilated retinal examination by an ophthalmologist, tonometry, lens and fundus photography, and a suprathreshold visual field test. Visual impairment was defined as a best-corrected acuity in the better-seeing eye worse than 20/40 and better than 20/200, while blindness was acuity in the better-seeing eye of 20/200 or worse. For those with a visual acuity worse than 20/40 in either eye, one or more causes were assigned by an ophthalmologist and a final cause for each eye was confirmed by a panel of 3 subspecialty ophthalmologists (O.D.S., H.A.Q., and S.B.B.) based on all available evidence. RESULTS: Bilateral presenting acuity worse than 20/40 increased from 4% in the 65- to 74-year age group to 16% in the 80- to 84-year age group. One third of those with presenting acuity worse than 20/40 improved to 20/40 or better with refraction. Overall, 4.5% had a best-corrected acuity worse than 20/40. African Americans were more likely to remain visually impaired than were whites despite refraction (odds ratio [95% confidence interval], 1.7 [1.1-2.6]). Whites were most often impaired or blind from age-related macular degeneration (1.2% vs 0.5%; P=.09). African Americans had higher rates of impairment and blindness from cataract or posterior capsular opacification (2.7% vs 1.1%; P=.006), glaucoma (0.9% vs 0.1%; P=.006), and diabetic retinopathy (1.2% vs 0.2%; P=. 004). CONCLUSIONS: More than half of those with visual impairment or blindness had conditions that were either surgically treatable or potentially preventable. African Americans had a disproportionate number of blinding diseases, particularly those amenable to eye care intervention. Targeted interventions for specific populations to increase appropriate eye care use would greatly improve vision and function in older Americans. Arch Ophthalmol. 2000;118:819-825

Aged↗
PubMed1994

The value of Medicare statistics in monitoring Pap smear screening. Screening versus non-screening smears: the role of the laboratory.

In November 1991 separate Medicare item numbers were introduced to distinguish screening from non-screening cervical smears for the purposes of monitoring the screening programme. Referring doctors are now expected to indicate the appropriate item number on the request form accompanying the Pap smear. To test compliance with this requirement, we examined 1000 consecutive request forms for cervical smears received in August 1993. We found that 22.7% had no item number indicated and that for a further 10.4% the item number given appeared to be incorrect. As the account issued by the laboratory must show an item number the ultimate responsibility for the choice of the item number rests with the laboratory. Using the guidelines supplied by Medicare, we formulated detailed criteria to classify smears as screening or non-screening, based on the patient's past smear history and/or clinical information provided by the referring doctor. Applying these criteria to cervical smears received in this laboratory in 1993 resulted in 70% being classified as screening and 30% as non-screening smears. Analysis of the cytological predictions for these smears showed substantially higher rates for all grades of abnormalities in the non-screening smears, thus lending support to the validity of our classification system. We conclude that classifying smears into screening and non-screening categories provides valuable information for statistical and quality assurance purposes but can only be useful for monitoring purposes if the criteria for assigning smears are applied consistently by all doctors and laboratories.

Australia↗
PubMed1994

Informal caregiving as state Medicaid expenditure: an only slightly immodest proposal.

States and Medicaid recipients would be better off if the federal Medicaid program allowed states to assign a dollar value to some unpaid care friends and family give to Medicaid recipients. The dollar value of this unpaid labor would then be counted as state spending in the calculation of federal match. The proposal, which would ease the pressure on tight state budgets, is entirely compatible with the recent federal-state compromise regarding provider taxes and donations and reinforces an important but overlooked Medicaid policy that cultivates and relies upon households to deliver care.

Budgets↗
PubMed1998

CM program helps make hospital profitable.

By implementing a case management program for the first time last year, Bradford Regional Medical Center (PA) managed to turn around a trend in which the 150-bed hospital lost $2.6 million in operating expenses in 1997. Case managers were assigned not to units but to groups of physicians to gain physician trust before focusing on resource utilization. Since the department was formed, the hospitalwide length of stay has dropped by half a day. The next step in the development of the program is to extend it beyond acute care into physicians' offices and into Bradford's nursing home to reduce rehospitalization, particularly for congestive heart failure patients.

Case Management↗
PubMed2000

HCFA's final rule on APCs is out: ED managers can breathe sighs of relief.

The final rule on ambulatory payment classifications (APCs) for outpatient services from the Health Care Financing Administration (HCFA) was published in the April 7, 2000, Federal Register, with a July 1, 2000, implementation date. EDS might receive increased reimbursement for services under APCs, in sharp contrast to previous predictions of a 15% decrease in reimbursement. Instead of combining CPT and ICD-9-CM coding for clinic and emergency visits APCs, HCFA has assigned three APCs for the emergency department and a fourth APC for critical care. There is no APC for a medical screening exam, which could improve reimbursement. There is no separate APC for observation services, which means no additional payment will be given. You can continue to use your current charge structure and correlate present levels of service with the appropriate CPT visit level. You will have to "unbundle" visit levels to list nursing and physician procedures separately as specific line items.

Ambulatory Care↗
PubMed2003

Treatment of behavioral emergencies: a summary of the expert consensus guidelines.

OBJECTIVES: Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely, but there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague. A significant number of deaths of patients in restraint has focused government and regulators on these issues, but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community. The authors assembled a panel of 50 experts to define the following elements: the threshold for emergency interventions, the scope of assessment for varying levels of urgency and cooperation, guiding principles in selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions. METHOD: A written survey with 808 decision points was completed by 50 experts. A modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options. Consensus on each option was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/ alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables were constructed describing the preferred strategies in key clinical situations. RESULTS: The expert panel reached consensus on 83% of the options. The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors. When asked about the frequency with which emergency interventions (parenteral medication, restraint, seclusion) were required in their services, 47% of the experts reported that such interventions were necessary for 1%-5% of patients seen in their services and 32% for 6%-20%. In general, the consensus of this panel lends support to many elements of recent regulations from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services), including the timing of clinician assessment and reassessment and the intensity of nursing care. However, the panel did not endorse the concept of "chemical restraint," instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood. Control of aggressive behavior emerged as the highest priority during the emergency; however, preserving the physician-patient relationship was rated a close second and became the top priority in the long term. Oral medications, particularly concentrates, were clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone. A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression. There was equal support for high-potency conventional or atypical antipsychotics (particularly liquids) in oral combinations with benzodiazepines. Droperidol emerged in fourth place in some situations requiring an injection. CONCLUSIONS: To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care settings regarding the relative merits of various strategies.

Journal Article↗
PubMed2000

Clarifying selected CPT modifiers.

This discussion includes only 20 percent of the modifiers available for physician reporting, but could account for 80 percent of modifiers assigned for physician services. Modifier -91 was the only new modifier introduced in CPT 2000 and it is used to report a repeat clinical diagnostic laboratory test. It is not to be used when confirming initial results or for any other reason other than a clinical need to repeat the test for the same patient on the same day. Success with CPT modifier reporting requires a thorough review of CPT guidelines and some detective work for identifying health plan requirements for modified codes.

Abstracting and Indexing↗
PubMed1988

An examination of the relationships between home health service use and primary diagnosis of patient.

This paper analyses the relationships between home health service use and primary diagnosis of patient. Relationships examined include: patient distribution by diagnosis, visit distribution by diagnosis, average number of visits per patient and standard deviation, by diagnosis. Reliability of diagnosis as a predictor or service use is examined by a scatter graph comparison of the mean number of visits per patient, by diagnosis, between two randomly assigned groups of agencies. Survey data indicate that circulatory system diseases are the largest diagnostic category in both patient and visit count, constituting approximately 25% of all visits. Neoplasms (11% of visits) and diseases of the musculoskeletal system and connective tissue (10% of visits) are also strongly represented. Although the range of means for average number of visits is large, the scatter graph analysis gave evidence of relationship between diagnosis and service use.

Catchment Area, Health↗
PubMed1988

The cost and efficacy of home care for patients with chronic lung disease.

A randomized controlled trial was conducted to assess efficacy and cost of sustained home nursing care for patients with chronic lung disease. Three hundred one patients were randomly assigned to a respiratory home care group (RHC) that received care from respiratory home care nurses, a standard home care group (SHC) that received care from regular home care nurses, or an office care group (OC) that received whatever care they needed except for home care. Patients were followed for 1 year. At the end of the study year, there was no difference in survival, pulmonary function, or everyday functioning among the three groups. Average annual cost of care for all study patients was $7,647 (1981-82 dollars). The average annual health care costs for patients in the RHC group was $9,768; for those in the SHC group, $8,058; and for those in the OC group, $5,051 (F = 6.45, df = 2/298, P = 0.02). These results suggest that the current policy of limited coverage of home nursing services by Medicare and other third-party payers may be appropriate.

Activities of Daily Living↗
PubMed1991

DRGs: the state of the art, circa 1990.

The history, up to 1990, of operational DRG systems in the United States is described from the viewpoint of changes to the patient classification system. Uses of DRGs, the DRG assignment process and the clinical verification steps are also described. The DRG classification process has become more precise over the last decade in both detail and structure. The annual revision process used in the U.S. is outlined with a detailed summary of historical changes. Recent improvements to DRGs have been directed towards a higher degree of precision as regards patient severity and related resource intensity. Recent research into modifying DRGs to better account for complexity or severity is presented with some scenarios for future developments.

Abstracting and Indexing↗
PubMed1990

Primary nursing in long-term care: is it economically feasible?

1. The demand for nursing home beds exceeds supply, creating a sellers market. Administrators, therefore, do not see the need for making costly changes in the method of nursing care delivery. 2. ++Modified primary nursing, where permanent RN-nursing assistant teams are accountable to a permanent patient assignment, can be budget-neutral. Studies have suggested that primary nursing decreases supply costs, the use of sick leave, and the total number of staff. 3. For primary nursing in long-term care to be feasible, there must be an adequate number of budgeted full time employees, an adequate supply of RNs who are willing to work in long-term care, and adequate salaries to attract competent staff. 4. Although research addressing the costs of implementing primary nursing in long-term care exists, it is largely anecdotal. More controlled studies are needed.

Aged↗
PubMed2006

Changes in critical care beds and occupancy in the United States 1985-2000: Differences attributable to hospital size.

OBJECTIVE: To determine the relationship between hospital size and changes in the number of critical care medicine (CCM) beds, proportion of hospital beds allocated to CCM, and CCM occupancy in acute care hospitals in the United States from 1985 to 2000. DESIGN: A 16-yr (1985 to 2000) retrospective analysis was performed using the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, MD) on U.S. acute care hospitals that provided CCM. Hospitals were stratified into four groups (small, 1-100 beds; medium, 101-300 beds; large 301-500 beds; and extra large, >500 beds). SETTING: Nonfederal, acute care hospitals with CCM units in the United States. SUBJECTS: None. INTERVENTIONS: None. MEASUREMENTS: Changes in the number of hospitals, non-CCM and CCM beds, the proportion of CCM to hospital beds, and their occupancy rates. MAIN RESULTS: Between 1985 and 2000, the number of hospitals providing CCM decreased overall (4,150 to 3,581, -13.7%). The greatest decreases were seen in large (-39%) and extra-large (-40%) hospitals. Small hospitals increased minimally (3.3%). The number of non-CCM beds decreased (820,300 to 566,900, -30.9%), most prominently in large (-44.2%) and extra-large (-46.1%) hospitals. In contrast, CCM beds increased overall (69,300 to 87,400, 26.1%), especially in small (27%) and medium (44.2%) hospitals. The proportion of total hospital beds assigned to CCM increased (71.8%), most markedly in large (93.5%) and extra-large (85.7%) hospitals. Non-CCM occupancy decreased (-6.4%), particularly in small (-7.5%) and extra-large (-5.8%) hospitals. However, regardless of hospital size, CCM occupancy changed negligibly (0.4%). At every time point studied, CCM occupancy was greater than non-CCM occupancy within each size group. As hospital size increased, occupancy rates increased. CONCLUSIONS: Across hospitals of all sizes, CCM bed numbers are increasing, whereas non-CCM bed numbers are decreasing. Although the CCM bed capacity is increasing at a greater percentage rate in smaller hospitals, the assignment of hospital beds to CCM remains higher in the larger hospitals. In addition, CCM bed occupancy is greater in larger institutions. These findings may help guide the future development of hospital size-based CCM benchmarking standards and guidelines.

Bed Occupancy↗
PubMed1992

Reimbursement of biotherapy: present status, future directions--perspectives of the office-based oncology nurse.

Economic forces are stimulating cost sensitivity and the need for clinical efficiency in medicine. The federal government has led the way with Medicare reform, and cost-containment efforts are evident in all health care payer programs. More and more, the office-based oncology nurse is involved in reimbursement issues as both a colleague and a patient advocate. Creative solutions to the challenges of reimbursement require knowledge of the issues, familiarity with patient-specific therapies, and recognition of unique cost and billing issues. Biologic agents frequently used in office-based oncology practice are easy targets for reimbursement denials because of regulations against their investigational status, "off-label" use, method of administration, and relatively high cost. Such agents include interferon, erythropoietin (EPO), granulocyte and granulocyte-macrophage colony-stimulating factors (G-CSF and GM-CSF, respectively), and interleukin-2 (IL-2). Reimbursement decisions are often characterized by inconsistency and uncertainty, and rulings are based not only on law, but also on interpretation. The need for clarification often opens a window for negotiation for the complex reimbursement issues associated with biotherapy. In addition to thoroughly determining cost and accurately assigning appropriate Current Procedural Terminology (CPT) codes, office-based oncology nurses can pursue various strategies to help their patients and practices obtain reimbursement of biotherapy. Chief among these is educating third-party payers on the appropriateness and necessity of newer treatment modalities. In individual cases, documentation of the scientific data, clinical outcomes, and cost benefits supporting a treatment decision almost always gains reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Allocation↗
PubMed2003

The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial.

BACKGROUND: While reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders. METHODS: We conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominantly Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt. RESULTS: Intervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08-1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07-1.89). CONCLUSIONS: In the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders.

Adult↗
PubMed1999

A cost-effectiveness and cost-benefit analysis of contingency contracting-enhanced methadone detoxification treatment.

We examined treatment costs in an ongoing study in which 102 opioid-addicted patients had been randomly assigned to either 180-day methadone detoxification or the same treatment enhanced with contingency contracting. In the latter condition, study participants received regular reinforcers contingent on negative urine toxicology screens and breath analyses for a range of drugs and alcohol. Both conditions involved psychosocial treatment, and all participants were stabilized to a daily methadone dose of approximately 80 mg during the first 4 months, followed by a 2-month taper. Individuals participating in the enhanced condition were more likely to provide continuously drug-free urine samples and alcohol-free breath samples during the final month of treatment than were participants in the control condition. Cost of treatment was calculated individually for each participant based on actual services received. First, unit cost for each service was determined, including adjusted staff salaries for direct treatment and opportunity cost of facilities utilized during service delivery. Next, we valued each patient's use of services during the first 120 days of the study and then added the cost of methadone, laboratory work, and contingent reinforcers. A subsample (n = 45) also provided data on health care utilization during treatment, which we valued using standard Medicare unit costs. The marginal cost of enhancing the standard treatment with contingency contracting was approximately 8%. An incremental cost of $17.27 produced an additional 1% increase in the number of participants providing continuously substance-free urine and breath samples during month 4 of the study. For every additional dollar spent on treatment, a $4.87 health care cost offset was realized; however, this difference was statistically insignificant due to extreme variances and small subsample size.

Cost-Benefit Analysis↗