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At least 919 records · Page 51Linked to original sources
PubMed1991

Have hospital inpatient cost containment programs contributed to the growth in outpatient expenditures? Analysis of the substitution effect associated with hospital utilization review.

The rapid increase in outpatient expenditures has been the focus of growing attention in recent years. This increase has corresponded with public and private efforts to contain hospital inpatient costs, prompting some analysts to suggest that outpatient expenditure growth is the result of a substitution effect; that is, the substitution of outpatient for inpatient care associated with hospital cost containment programs. Claims data on 43 privately insured groups that adopted utilization review (UR) during the latter part of 1984 or early 1985 were analyzed, comparing outpatient expenditures before and after adoption of hospital inpatient UR to quantify the substitution effect associated with UR. UR was not associated with higher physician office expenditures nor with higher outpatient diagnostic expenditures. UR was related to significantly higher hospital outpatient department expenditures. On average, these expenditures were approximately 20% higher (P = 0.01) after the adoption of UR. However, outpatient department expenditures of the groups analyzed represented a fairly small percentage of total medical expenditures; hence, the absolute expenditure increase was quite modest, on the order of $9 per insured person per year. This analysis, admittedly limited in scope, suggests that UR is associated with a measurable substitution effect. It is likely that inpatient hospital cost containment programs have resulted in some substitution of outpatient for inpatient care and thus have played a role in fostering outpatient expenditure growth during recent years.

Cost Control↗
PubMed1987

An access-oriented negotiated fee schedule. The Caterpillar experience.

This paper describes the system used by Caterpillar Corporation (CAT) in Peoria, Illinois, to reimburse surgeons. The CAT system assures access for Caterpillar employees and their families to a selection of qualified surgeons, while achieving cost savings through improvements in processing of surgical claims and negotiation of selected fees. CPT-4 codes are recorded for greater accuracy, when indicated, surgical services that have been incorrectly unbundled are rebundled, and the appropriateness of surgical assistant charges is reviewed. A "degree of difficulty" relative value scale (DODRVS) of surgical services is periodically revised as technology changes. The DODRVS multiplied by a regional factor, determined by local market research, establishes the fee that CAT will pay the surgeon. Balance billing is permitted if the patient (1) is informed in advance by the surgeon that the fee will be higher than CAT will pay, and (2) knows that the service can be obtained from other local surgeons who will accept the CAT fee. The goal of the CAT method of surgeon reimbursement is to gain physician support for an access-oriented, market-driven negotiated fee schedule. Compared with a resource-based relative value scale RBRVS) methodology, the CAT system is not formula-driven and depends on physician acceptance.

Fee Schedules↗
PubMed1998

Social insurance cost of standard discectomy and percutaneous nucleotomy. A retrospective study of 87 social insurance claim files of male blue collar workers.

A retrospective review of social insurance claim files of male blue collar workers was conducted to compare the social insurance costs of percutaneous lumbar nucleotomy with standard lumbar discectomy ; 29 percutaneous nucleotomy procedures were matched with 58 standard discectomies all carried out between January 1992 and December 1994. It was concluded that a standard discectomy procedure results in significantly higher costs during hospitalisation with respect to surgery, anaesthesia and hospital stay. A percutaneous nucleotomy leads to a significantly higher outpatient expenditure especially in radiology and medical devices. The relative proportion of outpatient practitioner's visits and hospital stay costs was significantly higher for the standard discectomy whereas medical devices had a relatively higher share in outpatient expenditure for the percutaneous nucleotomy. In this population of 87 compensation claimants, the average social insurance costs did not significantly differ between the percutaneous nucleotomy and the standard discectomy.

Absenteeism↗
PubMed2002

A retrospective analysis of the revocation of prior authorization restrictions and the use of antidepressant medications for treating major depressive disorder.

BACKGROUND: The California Medicaid (Medi-Cal) program removed prior authorization restrictions for 2 selective serotonin reuptake inhibitors (SSRIs), fluoxetine and paroxetine, in May 1996. OBJECTIVE: This article documents how open access affected patient compliance and the likelihood of switching antidepressant therapies. METHODS: All Medi-Cal patients with a paid claim who had a diagnosis of major depressive disorder (MDD) from September 1994 through January 1999 were eligible. The impact of open access on patient compliance and drug switching was investigated using logistic regression models. Completed therapy was defined as 180 days of uninterrupted drug therapy at a minimum therapeutic dose. RESULTS: A total of 6409 patient treatment episodes were identified, of which 80% involved the use of an antidepressant. The aggregate rate of drug therapy completion dropped from 23.2% before the change in formulary policy to 20.5% in the open-access period. There was no corresponding change in the likelihood of switching therapies. For fluoxetine-treated patients, the odds ratio for completing therapy relative to tricyclic antidepressant-treated patients dropped from 3.916 to 1.706 in the open-access period. Corresponding results for paroxetine-treated patients were 1.591 and 0.726, respectively. The reduction in the likelihood of completed therapy without a corresponding increase in switching is consistent with earlier results. Open access resulted in an influx of patients who were not previously treated with an antidepressant or reported by their physician as having an MDD. Physicians may have expanded the use of the open-access SSRIs to treat less severely ill patients. However, paid claims data do not provide sufficient information to accurately measure severity of illness. CONCLUSIONS: It is unclear whether patients benefited clinically from the expansion of the Medi-Cal formulary. The significant changes in the characteristics of the patient population in response to open access (access effect) complicate attempts to measure the impact of open access on treatment patterns. Future analysis of the impact of open access on the cost of treating an episode of depression will also have to address this issue.

Adult↗
PubMed1997

Patterns of anti-inflammatory therapy in the post-guidelines era: a retrospective claims analysis of managed care members.

Published and widely disseminated guidelines for the care and management of asthma characterize asthma as a chronic, inflammatory disease and propose specific recommendations for therapy with inhaled anti-inflammatory medications. In a retrospective analysis of medical and pharmacy claims data of approximately 28,000 asthmatic members from five managed care settings, the dominant pattern of pharmacologic therapy that emerged was the use of bronchodilators without inhaled anti-inflammatory drug therapy. In addition, a significant proportion of asthmatic patients received no prescription drug therapy for asthma. Less than one third of asthmatic patients received any anti-inflammatory therapy and the majority of these received one or two prescriptions per year. Specialist physicians were two to three times more likely than non-specialists during a study period of 1 year to prescribe an anti-inflammatory medication, and were half as likely to have their asthmatic patients experience an emergency department or hospital event. This database analysis suggests that greater conformity with guidelines and/or access to specialist physician care for asthmatic members will lead to improved patient outcomes.

Anti-Inflammatory Agents↗
PubMed2003

Cost of work-related injuries in insured workplaces in Lebanon.

OBJECTIVE: To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS: A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS: The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers. CONCLUSION: The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.

Accidents, Occupational↗
PubMed2001

An audit of medico-legal reports prepared for claims of psychiatric injury following motor vehicle accidents.

OBJECTIVE: The objective of this audit was to examine whether the content of medico-legal reports regarding psychiatric injury following motor vehicle accidents was influenced by the role of the report writers. METHOD: The audit consisted of a retrospective review, using a novel rating scale, of archived documents from 559 consecutively examined insurance claims following motor vehicle accidents in New South Wales. RESULTS: Treating practitioners wrote less complete reports than experts representing the plaintiff or defendant. Treating practitioners and plaintiffs' experts were more likely to diagnose posttraumatic stress disorder (PTSD) and depression, while defendants' experts were more likely to find no psychiatric disorder. Limitations of the study were that it was retrospective and examined report writing between 1989 and 1994. The completeness, rather than quality, of the medico-legal reports was measured. CONCLUSION: Further training and quality assurance procedures may improve medico-legal report writing. Reform of the rules regulating the content of experts' reports may reduce the extent to which the role of the report writer influences their opinion.

Accidents, Traffic↗