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PubMed1997

Medicare changes in the budget bill.

The 1997 federal budget bill contains several significant changes for the Medicare program. Of these changes, revamping of the Medicare capitation program probably has the potential for the greatest impact. This article explains how capitation payments will change under the new system. It also details key changes in Medicare payments to physicians and payments to hospital outpatient departments, rehabilitation hospitals, home healthcare providers, and nursing homes. Finally, several new benefits included in the budget bill are described.

Direct Service Costs↗
PubMed1998

Death investigation in Canada.

A survey of death investigation systems in Canada was conducted by questionnaire and included questions on the type of system used (coroner or medical examiner), budget, method of appointment and qualifications of coroners and medical examiners, responsible department of government, training requirements, laboratory facilities, and the utilization of investigators and pathologists by each jurisdiction. Of the population of Canada 81.5% reside in coroner jurisdictions, the primary death investigator in 81% of the population is a licensed physician. The majority of jurisdictions either require or provide training in death investigation. All death investigation systems are under the respective provincial or territorial department of Justice or Attorney General with the chief coroner or chief medical examiner appointed by their respective provincial cabinet. The qualifications of the chief coroner vary with jurisdiction, while in 75% of medical examiner jurisdictions the chief medical examiner must be a pathologist. On a per capita basis medical examiner systems are less expensive to operate than coroner systems.

Autopsy↗
PubMed1998

Economic outcomes with antidepressant pharmacotherapy: a retrospective intent-to-treat analysis.

Herein we describe a retrospective intent-to-treat evaluation designed to compare the natural course of antidepressant utilization and direct health service expenditures for the treatment of a single episode of major depression among patients enrolled in a multistate network-model health maintenance organization and initially prescribed either a tricyclic antidepressant (amitriptyline or nortriptyline) or the serotonin selective reuptake inhibitor (SSRI) fluoxetine. Patient-level paid-claims data for the period July 1, 1988, through December 31, 1991, were abstracted. During the above time frame, fluoxetine was the only SSRI available in the United States. Patients prescribed amitriptyline were more than three times as likely to require a change in antidepressant pharmacotherapy (OR = 3.27, 95% CI = 2.31 to 5.49), while patients prescribed nortriptyline were nearly four times more likely to change medication (OR = 3.82, 95% CI = 2.74 to 6.83) relative to patients initially prescribed fluoxetine. Consistent with our intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate analyses revealed that initiation of antidepressant pharmacotherapy with amitriptyline resulted in a 25.7% increase in per capita depression-related health service expenditures per year, while initiation of antidepressant pharmacotherapy with nortriptyline resulted in a 28.1% increase in per capita depression-related health service expenditures per year relative to patients initially prescribed fluoxetine. A financial break-even point was achieved at the conclusion of Month 5, at which time all three intent-to-treat cohorts had comparable health service expenditures in total. From a financial perspective, results stemming from this inquiry suggest that the initiation of antidepressant pharmacotherapy with an SSRI is warranted.

Adult↗
PubMed1998

An analysis of program and family costs of case managed care for technology-dependent infants with bronchopulmonary dysplasia.

Caring for technology-dependent infants with bronchopulmonary dysplasia requires a wide range and intense level of services. Case management programs can offer comprehensive services to patients with complex needs. The Neonatal Pulmonary Program at Tulane University Medical Center is a case management program for infants with chronic pulmonary problems. The purpose of this study was to describe the costs of providing care for technology-dependent infants with bronchopulmonary dysplasia and to include the direct and indirect costs to families as well as the Program costs. The study population included 89 infants enrolled in the program from September 1987 through February 1992. Outpatient, inpatient, and professional staff costs were derived from hospital and clinic billing information; all other costs were determined through family interviews. Total costs for outpatient services were $59,627 (89), professional team members time $185,539 (89); inpatient services $1,144,930 (89), professional costs for inpatient services $88,946; direct health costs $32,543 (37) for home health care, equipment, medications, special diets; direct non-health costs $30,670 (37) for transportation, meals, child care, lodging during clinic visits and rehospitalizations and household expenses to accommodate equipment needs; and indirect costs $26,173 (37) for missed work days and employment changes.

Bronchopulmonary Dysplasia↗
PubMed2005

A comparison of the cost-effectiveness of hospital-based home care with that of a conventional outpatient follow-up for patients with mental illness.

The purpose of this study was to compare the outcomes of a hospital-based home-care model with those of a conventional outpatient follow-up for mentally ill patients in Taiwan by means of cost-effectiveness analysis. The study design was a two group posthoc design. We interviewed 40 mentally ill patients who were followed up in the psychiatric outpatient department. Another 40 mentally ill patients who participated in a hospital based home care program were also interviewed. The outcome measures we used for interviews were disease maintenance behavior, psychotic symptoms, social function, service satisfaction, and cost. The cost for each patient was the sum of costs for all direct mental health services. The cost-effectiveness ratio showed that the costs of the hospital-based home care model (4.3) were lower than those of conventional outpatient follow-up (13.5) and that over a one-year period, the hospital-based home care model was associated with improvements in mental conditions, social functional outcomes, and service satisfaction. The improved outcomes and the lower costs in the hospital-based home care program support the view that it is the most cost-effective of the two. Policy makers may consider this analysis as they allocate resources and develop policy for the care of mentally ill patients.

Adult↗
PubMed2002

The economic burden of coronary heart disease in the UK.

OBJECTIVE: To estimate the economic burden of coronary heart disease in the UK using both direct and indirect costs. DESIGN AND SETTING: A prevalence based approach was used to assess coronary heart disease related costs from the societal perspective. PATIENTS: All UK residents in 1999 with coronary heart disease (ICD 9 codes 410-414 and ICD10 codes I20-I25). MAIN OUTCOME MEASURES: Direct health care costs were estimated from spending on prevention, accident and emergency care, hospital care, rehabilitation, and drug treatment. Direct non-health service costs were estimated from data on informal care. "Friction period" adjusted productivity costs were estimated using the human capital approach from lost earnings attributable to coronary heart disease related mortality and morbidity. The friction period is the period of employees' absence from work before the employer replaces them with other workers. Failure to adjust for this factor would overstate production loss. RESULTS: Coronary heart disease cost pound 1.73 billion to the UK health care system in 1999: pound 2.42 billion in informal care and pound 2.91 billion in friction period adjusted productivity loss; 24.1% of production losses were attributable to mortality and 75.9% to morbidity. The total annual cost of all coronary heart disease related burdens was pound 7.06 billion, the highest of all diseases in the UK for which comparable analyses have been done. CONCLUSIONS: Coronary heart disease is a leading public health problem in the UK in terms of the economic burden from disease. Cost estimates would be substantially understated if informal care/productivity costs were excluded.

Absenteeism↗
PubMed2004

The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study of Swedish patients.

The total costs for patients who are sick-listed due to back and neck problems have not previously been determined prospectively on an individual basis. This study aimed to determine the total cost to a society, based on individually assessed costs of health services and loss of production in people who are sick-listed 28 days or more for back or neck problems. Detailed data on individuals' health-care consumption due to back or neck problems was collected through prospectively entered diaries and questionnaires, after 4 weeks, 3 months, 1 and 2 years, in a consecutively selected cohort of 1,822 employed persons aged between 18 and 59 years. Costs for health care and production losses due to work absenteeism were determined individually and combined to render total costs to society. The costs for all medical services during the 2-year study were 6.9% of total costs for back and neck problems. The single most expensive medical service was surgery. Transferred to a national level, annual total costs for back and neck problems corresponded to 1% of GNP. In conclusion, direct health-service costs were a small fraction of the total costs, consequently indirect costs offer the greatest potential for savings.

Adult↗
PubMed1998

Effects of contracting and local markets on costs of public mental health services in California.

OBJECTIVE: This study examined the factors that determine whether mental health services provided under contracts with private providers are more cost-efficient than services provided directly by public mental health agencies. METHODS: Data on service costs for 1993 were obtained from the California Department of Mental Health cost reporting and data collection system and from a survey of local mental health departments. Ordinary least-squares regression was used to estimate the effect of contracting, local market conditions, and contracting procedures on unit costs of seven core mental health services: psychiatric inpatient care, rehabilitative day service, intensive day service, individual therapy, medication management, crisis intervention, and case management. RESULTS: Contracts with private providers significantly reduced costs for six core mental health services, but not for inpatient care. However, the extent of savings was affected by local market conditions, including the concentration of providers in an area, the provider organization's size, and the scope of services that the provider offered, as well as by contracting procedures-whether there was a formal contract review process and whether prices were negotiated with the majority of providers. CONCLUSIONS: The amount of cost savings that can be achieved from contracting with private providers is influenced by several factors, including competitive conditions in local markets. In some areas, direct provision of services by public mental health agencies may cost less. Contracting is a complex process that cannot be viewed as a panacea for improving cost-efficiency.

California↗
PubMed2005

Does additional care provided by a consumer self-help group improve psychiatric outcome? A study in an Italian community-based psychiatric service.

This study compares the two-year clinical and social outcome, the use of services and the direct costs of patients of the South-Verona Community Psychiatric Service who were members of a self-help group, with those who were not. Use of services and costs in the two years before the baseline were compared with those occurring two years after the baseline. Self-help subjects decreased their use of hospital stay as to number of admissions and days in hospital, with a reduction of costs; they were more satisfied as to work/education while non self-help matches presented an increase of unmet needs. Clinical and social outcome showed no significant difference. The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome.

Adult↗
PubMed1982

Involvement of a state society of hospital pharmacists in third-party reimbursement for nondistributive services.

The investigation by a state society of hospital pharmacists of the possibilities for third-party reimbursement for nondistributive services is described. A questionnaire was sent to all hospitals in the state to determine what nondistributive services were being performed that might qualify for third-party reimbursement. A committee was established to investigate what nondistributive services were being reimbursed separately and which nondistributive services had reimbursement potential, and to establish guidelines that hospitals might use in seeking reimbursement for these services. Of 150 hospitals in the state, 71 returned the questionnaire and 44 (62%) of those hospitals indicated that they offered at least one nondistributive service, but only two reported that they were receiving reimbursement. The committee found that there are two reimbursement mechanisms available to cover cost of nondistributive services: (1) direct billing of the third parties for the individual service, or (2) inclusion of the cost of the service with patient charges for drugs. After meeting with Blue Cross & Blue Shield, the major third-party payer in its state, the committee determined that BC & BS would reimburse the institution for the costs incurred in patient-care services plus an additional 13% overhead fee. In general, the cost of providing the nondistributive service should be reflected in the cost of the pharmacy operating budget, and reimbursement is made to the hospital rather than to the direct provider of the service. A statewide effort can help establish reimbursement procedures for nondistributive services and prevent duplication of efforts by individual institutions investigating reimbursement.

Health Education↗
PubMed2004

Screening mammography practice essentials.

A successful screening mammography practice has three directives. The first directive is quality mammography interpretation, which results in detection of a high percentage of early stage breast cancers, an acceptable recall rate, and an acceptable biopsy rate and yield. The second directive is providing a cost-efficient service. The third directive is access for as many eligible women as possible. Strategies that have helped improve screening mammography access for underserved women are discussed in this article.

Female↗
PubMed1977

The application of diagnostic specific cost profiles to cost and reimbursement control in hospitals.

A system has been developed to generate hospital budgets based on the types of patients served. Several hundred classes of patients are defined according to clinical attributes such as diagnoses and surgical procedures, and for each class a profile of resources consumed is determined. The class definitions are based both on homogeneity of patient care processes as well as resource consumption. These profiles are expressed as revenues generated by charging departments and as costs both direct and indirect for all services. A methodology has been developed to associate all indirect costs with their source for each service included in the profile. From a forecast of patient load by class, budgets can be computed from the cost profiles and revenues determined from the charging profiles. Further analysis thus can include the effect of changes in case mix as well as changes in patient care processes. The effect on revenues of different reimbursement mechanisms can also be projected as a function of the case mix. The system is currently being implemented for demonstration and evaluation of the Yale-New Haven Hospital.

Budgets↗
PubMed2001

Direct and indirect costs of dental trauma in Sweden: a 2-year prospective study of children and adolescents.

OBJECTIVES: To study total costs, including direct costs (health care service, loss of personal property, medicine and transport) and indirect costs (loss of production or leisure) of dental trauma to children and adolescents with special reference to predictors. METHODS: The study was based on a random sample of 192 children and adolescents with a dental trauma reported to an insurance company and prospectively followed up by telephone interviews over a period of 2 years. RESULTS: On average, health care service costs represented 2,955 SEK (SD=3,818) and total costs 4,569 SEK (SD=3,053) for dental trauma to permanent teeth, and 837 SEK (SD=898) and 1,746 SEK (SD=1,183) for trauma to primary teeth. The most extensive type of indirect cost was loss of production or leisure, which averaged 1,286 SEK (SD=1,830) for injuries to permanent teeth and 699 SEK (SD=1,239) for injuries to primary teeth. Multiple regression analysis of demographic and dental injury variables showed that complicated trauma was of special importance to costs for permanent and primary teeth injuries. The average relative increase in total costs to patients and companions for complicated injury to permanent teeth was 140% (95% confidence interval [CI], 66-248%) for patients and 132% (95% CI, 54-249%) for companions. Lack of access to a dental clinic near the place of residence could increase the average total costs of injuries to permanent teeth by 91% for companions (95% CI, 20-204%) and for primary teeth by 134% (95% CI, 38-296%). CONCLUSIONS: Dental traumas result in both direct and indirect costs, with a predominance of direct costs. The direct costs primarily depend on degree of severity, while indirect costs are mostly due to compromised access to health care service. Traumas to permanent teeth are especially costly and, due to additional maintenance, the care may continue for several years. This study has drawn attention to the significant implications of dental trauma to patient and companion, a new area where further studies are warranted.

Adolescent↗
PubMed2002

Domiciliary clinics II: a cost minimisation analysis.

OBJECTIVES: We compare the cost of assessing new referrals to an old age psychiatry service at the patient's home or a hospital-based clinic. METHOD: An old age psychiatry service in Liverpool where routine referrals were assessed at home (domiciliary clinic) was compared to an adjacent service which assessed people in an outpatient clinic. Activity levels for four years of the service were collected and analysed. A cost-minimization analysis was done using an algorithm which allowed all direct costs to the service to be taken into account. A sensitivity analysis changed key values of the algorithm allowing their relative contribution to be considered. RESULT: The domiciliary clinic was marginally cheaper than outpatient assessment (48 pounds sterling compared to 50 pounds sterling per successful assessment). The most important variables in determining the cost effectiveness of the service were non-attendance rates, the grade of doctor seeing the patient and the time spent traveling for the home assessment. CONCLUSIONS: Domiciliary initial assessments were comparable in cost to clinic assessments in this study but in other situations the cost will vary, depending on the key local variables.

Aged↗
PubMed1997

Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12 year study.

OBJECTIVE: To perform the first prospective longitudinal study of direct (health services utilized) and indirect costs (diminished productivity represented by income loss) incurred by patients with rheumatoid arthritis (RA) in Saskatoon and Montreal, followed for up to 12 and 4 years, respectively. METHODS: 1063 patients reported on health status, health services utilization, and diminished productivity every 6 months. RESULTS: Annual direct costs were $3788 (1994 Canadian dollars) in the late 1980s and $4656 in the early 1990s. Given that the average age exceeded 60 years, few participated in labor force activities or considered themselves disabled from the labor force and their indirect costs were substantially less, $2165 in the late 1980s and $1597 in the early 1990s. Institutional stays and medications made up at least 80% of total direct costs. Lengths of stay in acute care facilities remained constant, but the rate of hospitalization increased in the early 1990s, increasing average hospital costs per patient from $1563 in the late 1980s to $2023 in the early 1990s. For nonacute care facilities, rate of admission as well as length of stay increased over time, increasing costs per patient in Saskatoon 5-fold, from $291 to $1605. Those with greater functional disability incurred substantially higher direct and those under 65 years incurred higher indirect costs. CONCLUSION: Direct costs are higher than indirect costs. The major component is due to institutional stays that, in contrast to other direct cost components, is increased in the older and more disabled. Measures to reduce longterm disability by earlier, more aggressive intervention have the potential to produce considerable cost savings. However, it is unknown which strategies will have the greatest effect on outcome and accordingly, how resources can be optimally allocated.

Aged↗
PubMed1985

Cost-benefit analysis of a thalassemia disease prevention program.

We offer an economic perspective on prevention of beta-thalassemia disease by means of genetic screening and prenatal diagnosis in an established program in Quebec province. The program screens 80 per cent of at-risk persons in the high-risk communities, provides diagnosis to 75 per cent of at-risk couples, and prevented two-thirds of new cases in the period of study. We measured the additional costs, in 1981 Canadian dollars, of medical and public health resources, both incurred and avoided, resulting from use of these prevention services. The total direct cost per case prevented in the program is less than the cost for a single year of treatment for an individual with the disease. Sensitivity analysis accommodating demographic assumptions, participation rates, and discounting rates indicates that, even at rates of marriage, endogamy, and participation lower than observed in the current program, treatment costs will still exceed prevention costs when discounting is set at conventional rates of 4 per cent and 8 per cent. Cost effectiveness of the program is confirmed.

Cost-Benefit Analysis↗
PubMed1989

Utilization and outcome in the medical patient referred to surgery.

The objective of this study was to test the hypothesis that hospitalized patients referred to a general surgical service from a medical service for a surgical procedure would have higher hospital costs and longer lengths of stay per diagnosis-related group (DRG) than patients admitted directly to the general surgical service. Hospital costs by DRG, exclusive of physician's fees, were analyzed for all adult general surgical admissions treated at our hospital from January 1, 1985 to March 31, 1986 (3,028 patients) to yield a population of patients in those DRGs with patients referred to general surgery from medicine (1,495 patients). Patients within each DRG were then disaggregated by either direct admission to general surgery (1,412 patients) or referral to the general surgical service from the medical service (83 patients). Mean cost per patient was 146.5 percent higher for referral patients than for direct admission patients, as was the total length of stay. Mortality was higher for referral patients than for direct admission patients. Factors analyzed which contributed to this greater resource utilization and higher mortality were (1) a greater severity of illness, (2) higher diagnostic costs, and (3) delays in diagnosis or treatment. The DRG payment for referral patients also produced a substantial deficit for the hospital, whereas direct admission patients produced a profit of +1,105,596. This data suggests that direct admission to the surgical service of patients likely to need surgery might lower their hospital costs and improve the quality of their care.

Diagnosis-Related Groups↗