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PubMed2006

Centralized drug review processes: are they fair?

Numerous countries have implemented centralized drug review processes to assist in making drug coverage decisions. In addition to examining the final recommendations of these bodies, it is also important to ensure fairness in decision making. Accountability for reasonableness is an ethics-based framework for examining the fairness of priority setting processes. The objective of this study was to assess the fairness of four internationally established centralized drug review processes using accountability for reasonableness. Semi-structured telephone interviews were conducted with stakeholders in Canada, New Zealand, Australia and the UK (n=16). Participants were asked to evaluate their country's centralized drug review process against the four conditions of accountability for reasonableness. Each centralized drug review process satisfied at least one of the four ethical conditions, but none satisfied all four conditions. All participants viewed transparency as critical to both the legitimacy and fairness of centralized drug review processes. Additional strides need to be made in each of the four countries under study to improve the fairness of their centralized drug review processes. Ideally, a fair priority setting process should foster constructive stakeholder engagement and enhance the legitimacy of decisions made in assessing pharmaceutical products for funding. As policy makers are under increasing scrutiny in allocating limited resources, fair process should be seen as a critical component of such activity. This study represents the first attempt to conduct an international comparison of the fairness of centralized drug review agencies in the eyes of participating stakeholders.

Australia↗
PubMed1998

Federal-state joint board on universal service--FCC. Proposed rule; recommended decision.

On November 24, 1998, the Federal-State Joint Board adopted a Second Recommended Decision regarding universal service. In this decision, the Joint Board made numerous recommendations on universal service issues. The Joint Board recommends a federal high cost support mechanism for non-rural carriers that enables rates to remain affordable; that the Commission replace the 25/75 jurisdictional division of responsibility for high cost support; that the Commission compute federal high cost support for non-rural carriers through a two-step process; and that the mechanisms outlined be reviewed no later than three years from July 1, 1999. The Commission seeks comment on the Second Recommended Decision.

Costs and Cost Analysis↗
PubMed1980

Rate review: a look at state programs.

How have state-level budget/rate review programs fared across the nation?/A survey update reveals that 27 out of 51 hospital associations reported ongoing programs.

Data Collection↗
PubMed2006

'Participate to learn': a promising practice for community ABI rehabilitation.

OBJECTIVE: To identify best practices and promising practices to enhance participation in meaningful and productive activities. METHOD: An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed. RESULTS: Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation. CONCLUSIONS: 'Participate to learn' is both a credible rehabilitation model and deserving of more study.

Brain Injuries↗
PubMedDate not supplied

Obtaining organ donation: who should ask?

OBJECTIVE: To assess the impact of a decoupled presentation of the option of organ donation by an organ procurement organization representative on organ donation rates. DESIGN: Retrospective chart review. SETTING: A tertiary care university medical center. SUBJECTS: Patients declared dead by neurologic criteria during the 2-year period January 1, 1992, through December 31, 1993. INTERVENTION: The addition, for the calendar year 1993, of an institutionally dedicated organ procurement organization representative to present the option of organ donation with the use of the technique of decoupling. RESULTS: The rate of donation increased from 38% to 59% with the addition of an institutionally dedicated organ procurement organization representative and the routine use of decoupling. CONCLUSIONS: When a dedicated representative from the local organ procurement organization, rather than the physician, presents the option of donation and decouples the discussion of death by neurologic criteria from the presentation of the option of donation, the rate of donation significantly increases.

Academic Medical Centers↗
PubMed1984

Insurance and the disabled.

The provision of life insurance for the disabled has been investigated to determine the extent to which the perceived disadvantage expressed by some disabled groups was real and, if real, justified. Life cover for a particular disability is likely to be offered only by the few companies with experience of it; however, the ratings charged appear usually to be a fair reflection of the limited and often poor information available. The response of organizations for the disabled to this problem has been reviewed, and possible strategies to enable the disabled to obtain insurance are suggested.

Actuarial Analysis↗
PubMed2000

Physician compliance with warfarin prophylaxis for central venous catheters in patients with solid tumors.

PURPOSE: There is an established benefit of prophylactic warfarin in cancer patients with central venous catheters. This study assessed the compliance rate of prophylactic low-dose warfarin prescription in cancer patients with central venous catheters at a single institution. PATIENTS AND METHODS: Oncology patients with central venous catheters were identified by a retrospective chart review. Information retrieved included whether prophylactic warfarin had been prescribed and whether the patient had suffered a thrombotic or bleeding event. After the initial chart review, physicians were notified of the benefits of warfarin prophylaxis, and subsequently, a physician-independent mechanism of prescribing prophylactic warfarin was instituted. After each of these interventions, we retrospectively reviewed a further two cohorts of patients to assess compliance with warfarin prophylaxis. RESULTS: During the baseline study, only 10% of patients were prescribed prophylactic warfarin. After physician notification, the compliance rate increased to only 20% (P =.3). After instituting the physician-independent mechanism of prescribing prophylactic warfarin, the compliance rate increased to 95% (P <.001). The rate of catheter-related thrombosis was 11% for patients who were prescribed warfarin compared with 21% in those who were not anticoagulated (P =.2). CONCLUSION: At our institution, the rate of prescribing prophylactic warfarin was low in this patient population, and there was a reluctance of treating physicians to change their prescribing practice. Mechanisms exist to improve the rate of anticoagulant prophylaxis in this clinical setting. We recommend that institutions review their rate of compliance with prophylactic anticoagulation for patients with central venous catheters and solid tumors.

Anticoagulants↗
PubMed1990

Medicare program; update of ambulatory surgical center payment rates effective July 1, 1990--HCFA. Notice with comment period.

This notice implements section 1833(i)(2(A) of the Social Security Act, which requires that the payment rates for ambulatory surgical center services be reviewed and updated annually, and responds to public comments we received concerning the ambulatory surgical center payment rate update notice published on February 8, 1990 (55 FR 4577).

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Laboratory end-stage renal disease testing.

The Department of Health and Human Services, Office of Inspector General has incorporated end-stage renal disease (ESRD) into its 1999 Work Plan. Specifically, they will focus on identifying inappropriate Medicare payments for clinical laboratory services and their medical appropriateness. Under Medicare's composite rate reimbursement system, certain laboratory tests at established frequencies are covered under the composite rate. Any additional tests billed that are beyond the established frequencies must be supported by medical necessity. When billing laboratory tests for ESRD patients, it is important to know what tests are covered and at what frequencies under the composite rate. It also is important to understand the use of the 50/50 rule for determining whether automated multichannel tests are billable. This article reviews these details and provides insight into how laboratories should apply these rules when billing for ESRD testing.

Clinical Laboratory Techniques↗
PubMed1995

[Does the new Health Insurance Legislation lead to more competition? Consequences for physicians].

One of the goals of the new Swiss Health Insurance Law, which will be effective as of January 1, 1996, is to strengthen the market forces in the Swiss health care system. Although under the new law several barriers to competition will continue to exist, competition between physicians in private practice and between hospitals will have profound effects. In future physicians will have to accept responsibility not only for medical aspects but also for the financial consequences of their action. They will be confronted with new forms of reimbursement, utilization and cost reviews. Therefore, doctors will require training for their new role in a market-oriented health care system.

Economic Competition↗
PubMed1994

Blue Shield of California outpatient payment program.

Faced with major increases in the cost of outpatient medical care, Blue Shield of California initiated an effort to develop and implement a prospective payment system that could be used for contracting with hospitals and freestanding facilities. Utilizing an outpatient classification system designed to categorize outpatient visits with similar clinical characteristics as well as similar resource consumption, Blue Shield introduced a negotiated case rate system of payment for outpatient surgical care. This article will review the background of the project, the methodology used to implement the system, and the results achieved from its implementation.

Ambulatory Care↗
PubMed1992

Changes in Medicare capital PPS rates and rules.

Author Grimaldi discusses recent changes in Medicare's capital prospective payment system (PPS) regulations, published in the Federal Register, September 1992, as well as major changes in operating cost guidelines that affect capital payments. Policy interpretations that the Health Care Financing Administration (HCFA) has issued in the past year are reviewed, and changes made to the Medicare cost report in order to accommodate capital PPS are summarized schedule by schedule.

Capital Expenditures↗
PubMed1991

Development and application of a population-oriented measure of ambulatory care case-mix.

This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.

Adolescent↗
PubMed1990

Pricing of hospital services: issues and some propositions.

Pricing in relation to tangible products has been studied at great lengths by both economists and marketers. The pricing of services has received less attention. Only a few studies concerning pricing in the health care area have been conducted. A review of relevant pricing issues concerning services, and particularly health care, is presented. Several limitations of an existing pricing model for hospitals are discussed. Improvements are proposed.

Economic Competition↗
PubMed1983

State rate review and the relationship between capital expenditures and operating costs.

It is commonly assumed that an increase in capital expenditures leads to increased operating costs and a subsequent increase in rates, and thus that state rate review systems must incorporate certificate-of-need type controls over capital expenditures. The results of this study indicate that in those states with comprehensive rate review systems, increased capital expenditures may not lead to higher operating costs and rates; rather, increased wage rates are reflected in higher operating costs and rates. This pass-through of wages, and not capital costs, may have important policy implications.

Capital Expenditures↗
PubMed1979

Pathologists in New Jersey--an endangered species.

Pathologists in New Jersey are compensated in accordance with the rate established by the state's rate review commissions. The author of this article, while granting that the theory is a worthy one, explains that in practice the reimbursement procedure is causing the decline of the quality of health care in New Jersey.

Facility Regulation and Control↗
PubMed1984

Hospital rate review. A theory and an empirical review.

This paper presents a theory of the effects of rate review on hospital operations and organization. Its purpose is to explain the way in which hospitals have responded to regulation. In the development of this theory, the hospital product was viewed as a bundle of services, rate review was looked upon as a ceiling on the value of the bundle. The ceiling creates an incentive to remove elements from the bundle, i.e., to reduce 'quality'. When quality is variable, the effect on utilization becomes indeterminate. The model argues, among other things, that the hospital will change its service complement and its contractural arrangements with physicians and other hospitals. An extension of the organizational theory literature leads to implications concerning the ordering of hospital responses to regulation. The growing body of empirical literature on the effects of hospital rate review is used as an initial test of the major thrusts of the theory. A suggested agenda for further empirical work also is presented.

Cost Control↗