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The managed-care concurrent review process often results in denied or limited coverage of psychiatric inpatient care due to reviewers' misconceptions about psychiatric hospitalization and in an effort to achieve savings. For employers, such decisions may cost more in the long run.
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BACKGROUND: Provider claims data are used to make medical analyses and decisions, but such databases typically lack important clinical information. OBJECTIVE: To compare the patterns of use of filgrastim in analyses of a claims database and a medical chart review. METHODS: We extracted data from the Medicare 5% sample claims database for the years 1996 through 1998 and from a medical chart review of the Oncology Practice Pattern Survey (OPPS) for the same period to determine the patterns of use of filgrastim in patients with non-Hodgkin.s lymphoma treated with cyclophosphamide, doxorubicin, vincristine, and prednisone. The analyses were restricted to the first 3 cycles of the chemotherapy. RESULTS: A total of 414 patients in the Medicare database were treated with 1,360 cycles of chemotherapy. The mean duration of filgrastim use in these patients was 6.6 days. In the OPPS database, 80 patients were treated with 152 cycles of chemotherapy, with a mean duration of filgrastim use of 9.3 days. CONCLUSION: The mean duration of filgrastim use in the OPPS database was greater than that in the Medicare database and was closer to that shown in clinical trials to produce optimal results (approximately 11 days). The actual use of resources may be underestimated in claims databases, owing to their limitations and potential for bias.
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We compared course of treatment with tricyclic antidepressant drugs (TCADs) and selective serotonin reuptake inhibitors (SSRIs) to assess interactive effects of antidepressant type with payer type and patient characteristics. A nationwide sampling of adults (n = 4,252) from approximately equal numbers of health maintenance organization (HMO) and indemnity enrollees were prescribed no antidepressants for 9 months, and thereafter prescribed a TCAD or SSRI. Using a retrospective analysis of prescription claims, these cohorts of TCAD and SSRI utilizers were followed for 13 to 16 months after their initial antidepressant prescription. Outcome measures included (1) termination of antidepressant treatment before 1 month; and (2) failure to receive at least one therapeutic dose during treatment lasting 3 months or more. Rates of premature termination and subtherapeutic dosing were significantly higher for TCAD-treated than SSRI-treated patients, and for HMO than indemnity enrollees. The interaction of HMO enrollment and TCAD use was associated with particularly high rates. Excluding patients terminating in the first month, the proportions of TCAD and SSRI utilizers remaining in treatment over time were not significantly different. We conclude that SSRIs may provide advantages in treatment adherence and therapeutic dosing, particularly in environments with limited prescriber time. The first month of treatment may be especially critical in determining compliance.
OBJECTIVE: To evaluate the feasibility of using health-plan administrative data to measure potential drug-drug interaction (DDI) rates in the ambulatory setting at the medical-group level and to assess the potential use of DDI rates in performance measurement, quality improvement, and research in patient safety. STUDY DESIGN: We combined administrative and pharmacy claims data from 2 large health plans to calculate the rates at which member users of selected chronic medications were potentially exposed to a second drug known to pose a risk of harmful interactions. METHODS: We divided 44 medication combinations with risk of adverse interactions into those with DDIs of moderate/severe clinical significance and those with DDIs of mild significance. We then calculated yearly rates of potential DDIs in continuously enrolled members aged 19 and older from 1998 through 2001. Rates were calculated for all members, overall base-medication users, and, individual medical groups responsible for their care. RESULTS: The analytic data set included 756 047 patient-years of data and 110 to 123 medical groups per year. During the 4-year interval, one or more unique potential DDIs occurred in 6.2% to 6.7% of base-drug users and 2.0% to 2.3% of all adult health-plan members per year. Medical-group mean user rates were slightly lower (5.33%-5.81%), with wide variance (SD = 2.6%-3.1%) and high stability over time. CONCLUSION: Potential DDI rates calculated from health-plan data have promise for measurement in patient medication safety. This readily available and inexpensive evaluation tool has potential for monitoring, improvement, and research purposes if further studies validate their relationship to actual adverse events.
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An internal audit process is central to an effective compliance program. When based on pertinent Federal regulatory guidelines and executed by staff with appropriate technical expertise, an internal audit limits opportunities for noncompliant physician billing and reduces the risk of incurring financial penalties. The design of an effective internal audit process will incorporate uniform internal audit procedures, communication mechanisms, and educational initiatives to correct any deficiencies that are identified. For healthcare organizations that are involved with physician group practices, review of physician documentation is particularly important. This review provides essential information on potential areas of risk and offers a focus for future education of physicians regarding appropriate billing and documentation.
Many complex issues are associated with specialty pharmaceuticals in the development of a successful specialty pharmaceutical program. A previous article focused on the definition and scope of specialty pharmaceuticals. This article explores the mechanics of developing and managing a specialty pharmaceutical program, specifically, authorization management.
Usage of outpatient services has reached an all time high. Insurers and employers seek means to monitor the escalating costs for providing ambulatory care. This article offers insight about the objectives of managed care groups and what they are looking for in their outpatient utilization review endeavors.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
BACKGROUND: Clinical trials suggest that the risk of pneumonia and other sequelae of influenza may be reduced in patients using oseltamivir. RESEARCH DESIGN AND METHODS: This retrospective cohort study used U.S. health insurance claims data. Patients were grouped into three cohorts: (1) diagnosed with influenza-like illness (ILI) and received a dispensing of oseltamivir; (2) diagnosed with ILI but received no antiviral medication; and (3) received oseltamivir without a physician diagnosis of ILI. Baseline factors assessed included demographics, history of drug dispensings, diagnoses, and vaccinations. MAIN OUTCOME MEASURES: Outcomes included diagnosis of pneumonia, dispensing of an antibiotic, or hospitalization within 30 days after an ILI diagnosis or oseltamivir dispensing. RESULTS: The adjusted hazard ratio for ILI with oseltamivir compared to ILI without antivirals for pneumonia was 0.72 (95% CI, 0.60-0.86), for antibiotic dispensing was 0.89 (95% CI, 0.86-0.93), and for hospitalization was 0.74 (95% CI, 0.61-0.90). The cohort who received oseltamivir without an ILI diagnosis did not differ significantly in risk of any outcome from the ILI with oseltamivir cohort. CONCLUSIONS: The risk of pneumonia, antibiotic dispensing, and hospitalization was reduced in patients with ILI who received oseltamivir compared to no antiviral therapy. These findings were based on health care claims only and have not been verified through medical record review.