SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Plan design holds the key to managing mental health and substance abuse costs, Ms. Pflaum points out. She explains that utilization review, EAPs, HMOs and PPOs, and carve-outs can be useful in the process.
The purposes of this study were to identify the congruence of blood lead testing based on parental self-reports with Medicaid claims and blood lead surveillance records, and to determine factors associated with agreement between parental reports of blood lead tests and Medicaid claims or blood lead surveillance records. Data were obtained from a cross-sectional mailed survey of a randomly selected sample of parents of children 1-2 years old enrolled in Medicaid (n=532) and from existing Medicaid claims and blood lead surveillance records. Fifty-six percent of survey respondents reported their child had a blood lead test completed. Of these, only 56% could be confirmed with Medicaid claims/blood lead surveillance data. Logistic regression analysis revealed the odds of blood lead testing per parental report confirmed with Medicaid claims/blood lead surveillance data were 2.6 times greater if the child had > or =3 provider visits, 2.5 times greater if parents reported receiving a reminder about blood lead testing, 2.2 times greater if parents reported receiving information about lead poisoning, 1.6 times greater if residing in an urban county, and 1.5 times greater if the child was more than 2 years old. In conclusion, parents are not always aware if their child had a blood lead test. Information and reminders about blood lead testing should be distributed to parents of young children enrolled in Medicaid and frequently reviewed by healthcare providers.
OBJECTIVES: To (1) describe the rate of glycosylated hemoglobin (HbA1c) testing and control in a primary care clinic at an academic medical center; (2) compare academic medical center and health maintenance organization (HMO) data for a subgroup of the same patients; and (3) discuss the challenges to accurate clinical practice profiling. STUDY DESIGN: Retrospective analysis of medical records and claims and administrative data. PATIENTS AND METHODS: We reviewed the medical records of 300 patients with diabetes mellitus from the Primary Care practice at an academic medical center (AMC). The HMO and AMC were in the southeastern United States. The study adhered to the National Committee for Quality Assurance's Health Plan Employer Data and Information Set 3.0 (1998) guidelines for collection of the numerator and denominator data. RESULTS: Overall, 275 (91.7%) of 300 patients underwent a documented HbA1c test (range, 77.8%-98.0% across the 5 Primary Care Associates clinic physicians). Of these 275 patients, 206 (74.9%; range, 52.4%-84.7%) were under "good control" (defined by the National Committee for Quality Assurance as an HbA1c level of < or = 9.5%). The mean (SD) HbA1c level was 8.45% (1.98%). Data from the HMO documented a rate of HbA1c testing of 36.3% (45/124) compared with 92.7% (115/124) based on case note review at the academic medical center. CONCLUSIONS: Current administrative and claims-based information systems have inherent weaknesses if used for performance measurement. Reliance solely on medical record review is time and cost prohibitive. To ensure complete reporting of mandated "quality measures" will necessitate the tracking of data across different healthcare systems.
In a recent California appellate decision, Wilson v. Blue Cross of Southern California, 222 Cal. App 3d 660, 271 Cal Rptr 876 (2d Dist., 1990), the court cut back on its earlier decision in Wickline v. State of California, 192 Cal. App. 3d 1630, 239 Cal Rptr 810 (2d Dist. 1986), which had provided substantial protection for third-party payers against liability for utilization review decisions. The Wilson decision not only limits Wickline to its particular facts, but also criticizes some of its rationale.
Medication errors are a frequent cause of medical malpractice claims. Because serious injury often results, medication errors can be costly to defend, indemnify or settle. A review of five closed claims involving glucocorticoids, corticosteroids, antibiotics and silver nitrate offers insight into how ophthalmologists can protect themselves against medication malocurrences.
Closed claims analysis of adverse anesthesia outcomes was initiated through the AANA Foundation in 1995 to examine adverse outcomes of anesthesia care provided by Certified Registered Nurse Anesthetists (CRNAs). A research team of 8 CRNAs using an instrument incorporating more than 150 variables undertook document analyses of closed claim files. All files reviewed involved incidents in which the CRNA named in the policy was potentially involved in the adverse patient outcome. Thirty-eight percent (58/151) of CRNA-related claims involved a respiratory incident as the primary cause of the negative patient outcome. Patient outcomes involving respiratory incidents were more likely to result in death or permanent injury compared with nonrespiratory incidents (P < .01). Reviewers found that respiratory claims were more likely to have involved inappropriate anesthesia management (P < .01), more likely to have involved a lack of vigilance (P < .01), and more likely to have been judged by the reviewer as preventable (P < .01). A higher percentage of respiratory incidents occurred in emergency cases (75% vs 34%, P < .01) and in cases involving general anesthesia (44% vs 17%, P < .01). Adverse respiratory incidents are largely preventable and frequently result in serious patient morbidity and mortality.
Practice Bulletin is the first in a series to be presented at the behest of the Council on Professional Practice, in response to issues arising in medical record practice today. Clear, useful points listing areas of responsibility as well as policies and procedures are given for both the private review organization, a new protagonist seeking access to patient records, and the facility, traditional guardian of health care records.
"Norsk Pasientforening" (The Norwegian Patients' Association) is an independent organization which, since 1983, has advised patients wishing to complain about medical treatment. A questionnaire was sent to a sample of patients who had been in contact with the organization to find out how they felt their complaint had been handled, and how they wished to channel complaints in future. Patients would like to have a review board in their own locality, and think that the complaint should be examined by a lawyer and a physician. This review board should be capable of taking decisions and awarding compensation. The complaints would also like to have a spokesman to argue for their legal rights.
Home care agencies must become aware of the claims targeting process within medical review, undertake steps to prevent adverse claim determinations, and adjust strategies when responding to these decisions through the administrative appeals process.
Health maintenance organizations (HMOs) must expand their appeals process for Medicare members needing care urgently. They also must now accept any physician's conclusion that the member's medical circumstances warrant expedited review, regardless of whether the physician is part of the HMO's network. HMOs must inform their Medicare members how to navigate the appeals maze.
STUDY OBJECTIVE: Anecdotal concerns suggest that health management organization (HMO) membership instructions may deter members from calling 911 or going to an emergency department for a perceived emergency. This study examines such instructions, specifically in regard to their definition of an emergency condition and associated instructions. METHODS: Member instructions were requested from 28 HMOs in 3 large West Coast cities with HMO penetration exceeding 30%. Fifteen (54%) provided membership materials. Features examined included the definition of an emergency, instructions for calling 911, specific instructions regarding chest pain and stroke, and mention of costs associated with emergency care. RESULTS: Instructions and definitions varied widely. Six HMOs (40%) included chest pain in their definition of an emergency; 2 (13%) included symptoms of stroke. Ten (67%) made mention of calling 911 or going to the ED somewhere within their instructions; 4 (27%) provided no options for calling 911 or seeking ED care. Three (20%) cited higher costs associated with ED care. Eleven (73%) indicated that claims would be denied for visits determined on retrospective review to be nonemergencies. CONCLUSION: Instructions varied considerably. Most did not include chest pain or symptoms of stroke in their definition of an emergency. Most did include directions to call 911 or go to an ED. Other instructions may lead members to call the HMO first during an emergency.
Many factors are involved in improving the quality of health care. Using data to measure performance is an essential element. Whether the objective is to improve outcomes (e.g., reducing mortality among patients hospitalized with acute myocardial infarction) or to improve a process of care (e.g., increasing the rate of beta blocker administration at discharge in patients with acute myocardial infarction), data are central to assessing the quality of health care. Data help determine where opportunities for improvement exist and document the impact that system change interventions have made on the outcomes or processes of care for a clinical condition or topic. Measuring performance is critical to learning how your practice compares with best practices. If you haven't measured, you do not know. This article will focus specifically on the role and use of data to improve processes of health care for Medicare beneficiaries. Examples of projects and results are cited from the work of the Texas Medical Foundation, which is the Medicare peer review organization under the Health Care Financing Administration's Health Care Quality Improvement Program.
Connecticut Medical Insurance Company (CMIC) cases related to obstetrical care and the newborn represent the single most costly exposure to the Company. CMIC undertook the review of its perinatal cases, open and closed, to identify common elements that increased the liability exposure of individual physicians as well as the overall exposure to the Company.
These final regulations (1) revise Medicaid rules to reflect current policy on State payment of cost sharing amounts under Medicare Part B "buy-in" agreements; (2) revise and clarify certain Medicaid definitions; (3) remove the requirement that State plans include third party liability quality control reviews as part of the State's Medicaid quality control systems; and (4) provide for limitations on the use of Federal funds for abortion. These final regulations allow States with Medicare Part B buy-in agreements the option of paying cost sharing amounts for Medicaid beneficiaries for those Medicare services that States do not cover in their Medicaid plans. States may pay cost sharing amounts under Medicare Part B buy-in agreements on all, some or none of the Part B Medicare services that are covered in the Medicaid plan. We are revising definitions and clarifying ambiguities in several existing Medicaid regulations. The revisions are to the definitions of private duty nursing services, inpatient and outpatient, inpatient and outpatient hospital services, and other laboratory and x-ray services. We are removing the requirement in our quality assurance regulations that States monitor third party liability errors as a part of their quality control system. Instead, we plan to issue regulations which encourage improved third party liability (TPL) operations by making them an integral component of State Medicaid Management Information System subject to periodic evaluation through systems performance reviews. We are revising the Medicaid regulations to provide for limitations on the use of Federal funds for abortion, in accordance with previously enacted laws.
Successful outcome for the traumatically brain-injured (TBI) patient is dependent on both a productive clinical therapy program and an effective case-management strategy by the carrier. This retrospective study focuses on identifying those case-management techniques which contributed to improvement in the disability, living, and occupational status of patients in a post-acute rehabilitation program. Statistical analysis indicated a positive relationship between two case-management factors and improved patient outcome. Additional analysis demonstrated predictive qualities of specific admission data for patient program cost. A review of these case-management techniques and their impact on discharge disability, living, and occupational status will be discussed.
Managed Care Organizations (MCOs) have turned to numerous cost-containment measures to combat rising healthcare costs. One of the most common is the use of utilization review to ascertain whether a recommended mode of treatment is "medically necessary." When the medical director of an MCO determines that care recommended by a patient's treating physician is not medically necessary and not eligible for coverage (and, as a result, potentially unattainable due to cost), the stage is set for litigation. In such situations, medical directors may become potentially liable for disciplinary action by their state medical licensing board as well as lawsuits for malpractice or negligence. However, plaintiffs wishing to recover damages for improper determinations of this nature or state boards trying to discipline these physicians, face the hurdles of the preemptive force of ERISA, and state doctrines to the effect that corporations (and, derivatively, their medical directors) cannot practice medicine and therefore cannot be liable for malpractice. Conflicting decisions and opinions make it impossible at the present time to have a settled expectation regarding the potential liability of medical directors in this context, although the law appears to be moving toward the treatment of utilization review as medical decisionmaking; therefore, it appears likely that the activities of medical directors increasingly will face state oversight--including the imposition of common law liability in appropriate situations.
This study evaluates the aggregate and temporal impact seven Blue Cross and Blue Shield Plan utilization management (UM) programs have on hospital utilization and payments over a nine-year period, 1980 through 1988. The impact of these programs is determined using a statistical model that controls for variations in organizational characteristics of 56 Blue Cross and Blue Shield Plans, the health care market of the individual Plan, and several state and federal health care regulations. The statistical results indicate that over the entire period 1980 to 1988, preadmission certification, concurrent review, and denial of payment (as a part of the retrospective review program) programs were associated with lower hospital admissions, and fewer inpatient days and payments per 1,000 members. Mandatory second surgical opinion did not have a statistical impact on hospital utilization and payments. The aggregate reduction in hospital payments for all Blue Cross and Blue Shield Plans with both a preadmission certification and concurrent review program was estimated at $2.55 billion in 1988 dollars. For those Plans conducting preadmission certification, concurrent review, denial of payment, and case management programs in 1988, the total per enrollee reduction of inpatient payments was $52.94.
The use of cost containment measures in utilization review is a continuing topic of concern to physicians and payors. Focusing on a recent California case that dealt with this issue, this article discusses the potential liability of physicians and payors when such measures are used.