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PubMed1989

Quality assurance and utilization review in a health insuring organization. The HealthPASS example.

HealthPASS is a Philadelphia-based health insurance organization (HIO), owned and operated by the Penn Health Corporation, a subsidiary of Maxicare, the large for-profit health maintenance organization (HMO) company based in California. In a contractual agreement with the Pennsylvania Department of Public Welfare (DPW), Maxicare contracts primary care physician services on a capitated basis, and other services on a fee basis, to about 96,000 Medicaid enrollees in certain zip codes in Philadelphia. Although HealthPASS does not provide care directly, it contracts with providers for these medical services. HealthPASS serves a primarily poor, minority, and inner city population with high rates of drug abuse, alcoholism, and mental illness. Currently, the enrollees are served by a network of providers including more than 40 participating hospitals and over 500 primary care providers (PCPs) in the community. HealthPASS is unique as previous HIOs in Kentucky and Arizona both failed. This paper describes the quality assurance and utilization review (QA-UR) system implemented by HealthPASS with specific examples of case discussions and a detailed look at the structure and function of the internal review process. Before outlining the QA-UR system, a brief history is provided of the recent controversial trend toward managed care for Medicaid recipients, as there have been marked failures in this arena nationally. The HealthPASS system is described--what it is, how it is staffed, who it serves, and the health services it offers.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Maintenance Organizations↗
PubMed1992

Utilization review savings at the micro level.

Utilization review (UR) programs have become an integral part of efforts to contain health care costs for private health insurers, employers, and health care organizations. While some studies have measured the overall performance of these programs, important information in the prior level of the health care utilization has not been used in estimating the effectiveness of the program for micro units (e.g., employer groups). In this article, the authors present a model to determine how the impact of the hospital UR program on health care utilization for specific groups varies with historical use patterns. The estimation approach used in this article can be used to determine the effect of UR for specific employer groups without having to rely on the average effectiveness measures for all. Claims obtained from Aetna Health Plans provided data for more than 5,300 employer accounts covering approximately 580,000 employees, 44% of whom had the UR program sometime during the period 1987 to 1990. Because of regression to the mean, UR savings were greater for units with higher prior use and smaller for units with lower use. In addition to prior use, the size of the group also determined the extent of regression to the mean. Groups with smaller number of enrollees had greater potential to save from the UR because of UR's ability to reduce the outliers.

Adolescent↗
PubMed1994

Methodological challenges and innovations in patient outcomes research.

Between 1989 and 1992, the Agency for Health Care Policy and Research (AHCPR) awarded funding to 14 special projects known as Patient Outcomes Research Teams (PORTs). These large, complex projects form the centerpiece of the first generation of research under the Medical Treatment Effectiveness Program. In carrying out their individual 5-year research plans, and through collaborative work of six Inter-PORT Work Groups, PORTs have contributed to methodological advances related to their specific clinical focus and to outcomes research in general. Each of the PORTs has followed a standard research model, involving the application of: systematic literature review, measurement of outcomes, analysis of cost and claims data, decision analysis, and strategies for disseminating findings. This article reports what has been learned by individual PORTs, and by AHCPR, regarding the usefulness of each of these methodologies, both for the ongoing projects and for the next generation of effectiveness research. Example from individual PORTs and work groups illustrate some of the methodological gains that have been made in effectiveness research and provide a glimpse of the work that remains to be done.

Analysis of Variance↗
PubMed2005

[Unexpected events in patient complaints and insurance cases at Hvidovre Hospital, Denmark, 2002-2003].

INTRODUCTION: The aim of this study was to do a systematic evaluation patients' complaints and insurance cases, to produce knowledge that will allow the prevention of future similar events. MATERIALS AND METHODS: 143 cases filed as patients' complaints or insurance cases during the period 1 January 2002-30 June 2003 were evaluated for the occurrence of adverse events. In the case of an adverse event, a classification score, ranging from mild to serious, was allotted based on the SAC matrix score. An audit of the case, involving the specialist who had treated the patient, was performed in all cases of serious adverse events. RESULTS: In 61% of the reviewed cases, an adverse event had occurred. It was estimated that in approximately 90% of the cases, the adverse events would not have been reported by the hospital staff, since they did not fit into the categories for mandatory reporting. In 38% of the cases where an audit was carried out, the event was found to have been preventable. DISCUSSION: The study shows that systematic evaluation of patients' complaints and insurance cases, plus audit, is potentially an effective method of preventing future adverse events.

Denmark↗
PubMed2000

A review of workers' compensation claims: the frequency of claim denial and medical treatment delay.

A retrospective chart review of 257 patients who presented between January to March 1998, was conducted to identify the frequency of workers' compensation claim denial among patients who reported to Straub Clinic and Hospital. Results showed that 12.8% of claims were either "denied" or temporarily "denied pending investigation". Analysis of all the claims found that only 2% resulted in delayed medical care. Further analysis of the denied claims revealed the vast majority of claims (78.8%) were denied because the medical provider and the patient had incorrect workers' compensation carrier information. Other independent variables studied (size of the employer, category of employer, injury type, status of case, length of case and number of visits) did not predict either denial of the claim or treatment delay. This study suggests that the efficiency of our State's Workers' Compensation system would be greatly improved by developing a system to provide medical care providers with accurate insurance information.

Accidents, Occupational↗
PubMed1999

Injuries and illnesses among hospital workers in Ohio. A study of workers' compensation claims from 1993 to 1996.

Occupational illnesses and injuries are common problems facing workers and employers. The purpose of this study was to determine the nature and extent of illnesses and injuries among hospital workers in Ohio. All workers' compensation claims for 22 hospitals in Ohio during the period 1993-1996 were reviewed. The majority of the claims were for sprain and strain injuries. Most of the claims were approved. Back injury was the leading cause of injury in both genders, and females reported a significantly higher percentage of back injuries. The incidence rates for injuries and illnesses were lower than national rates for other industries. Generally, there was a downward trend in the number of claims during the study period. A negative linear trend in injury rates by hospital size was detected. Our findings suggest the need for safety programs, especially in smaller hospitals, with the goal of preventing sprain and strain injuries.

Adult↗
PubMed1997

Is patient length of stay related to quality of care?

In this article, we investigate the relationship between hospital length-of-stay (LOS) and quality of care. We use hospital claims records from Medicare beneficiaries in Michigan to estimate condition-specific models for predicting patients' LOSs. With these models and a data set provided by Michigan Peer Review Organization, Inc. (MPRO), each patient's risk-adjusted LOS is then linked to a quality-of-care judgment (good care, poor care) from physician peer reviewers. LOS is a widely used indicator of hospital performance. Most commonly, it is viewed as an indicator of hospital efficiency and as a surrogate measure for costs, with hospitals having long average LOSs considered relatively inefficient in the use of resources and those with low LOSs considered to be efficient. Sometimes, however, LOS is assumed to relate to quality. For example, if hospitals were to respond to the financial incentives of prospective payment by attempting to lower costs by prematurely discharging patients, LOSs significantly lower than expected might be considered indicative of poor quality care. On the other hand, if poor quality of care causes complications, it would tend to extend LOSs. Under this assumption, longer than expected LOSs could be viewed as indicative of poor quality care. This article shows that in every one of the 13 clinical conditions examined, cases that received poor quality care had significantly longer risk-adjusted LOSs than cases whose care was of acceptable quality.

Health Services Research↗
PubMed1993

[Complaints about primary care physicians].

The most serious complaints against general practitioners are investigated and dealt with by the Directorate of Health. A systematic review of 100 cases of complaint from 1983 up to 21 May 1992 showed that 57 of them concerned an urgent need of medical assistance and deputizing service. One-quarter of the complaints concerned telephone consultations. Incorrect diagnosis was the most frequent reason for the complaint. More than half of the cases referred to acute somatic diseases and accidents. The results will be used jointly by the Directorate of Health and the Norwegian Medical Association to improve practice.

Diagnostic Errors↗
PubMed2002

Measuring breast, colorectal, and prostate cancer screening with medicare claims data.

BACKGROUND: Evaluating the use and effectiveness of cancer screening is an important component of cancer control programs. Medicare claims may be a useful source of data when screening older populations, but they are limited in terms of completeness and the ability to distinguish screening tests from those provided for diagnosis or surveillance. RESEARCH DESIGN: A review of the major screening modalities for breast, colorectal, and prostate cancer, Medicare's policies for covering these tests, and the procedure codes used to identify them in Medicare claims. RESULTS: Although Medicare's coverage has been extended to include screening mammography, colonoscopy, sigmoidoscopy, fecal occult blood tests, double-contrast barium enema, and prostate-specific antigen tests, providers have been slow to adopt the corresponding screening codes. CONCLUSION: Challenges persist in measuring screening use, and innovative approaches are required to distinguish screening tests from diagnostic and follow-up evaluations.

Aged↗
PubMed1999

Drug use and prescribing problems in four state Medicaid programs.

In this article the authors present population-level prevalence rates for 61 specific drug-related problems occurring in three State Medicaid programs (Maryland, Iowa, and Washington) from 1989 through 1996 and a fourth (Georgia) from 1994 through 1996. The findings represent the first application of a consistent drug utilization review (DUR) screener program to Medicaid data across States. The study finds major differences in DUR failure rates among the four States with the lowest rates in Georgia and the highest in Washington. Only Iowa showed any population-level reduction in DUR failure rates during the study period, however, rates for community-dwelling elderly fell in most States.

Drug Therapy↗
PubMed1994

Improving "medical necessity" acceptance by health care providers and consumers.

A major problem for patients and providers has existed since establishment of peer review and authorization agency medical necessity guide lines, because physicians and patients who receive denial of proposed procedures and tests on the basis of so called "medical necessity" presume that the authorization agency considers the proposed procedure or test to be medically unnecessary, meaning of no health value to the patient. This may well not be the case. Both providers and consumers can be expected to be more accepting of negative authorization decisions if the principles of continuous quality improvement are brought to bear on the authorization process.

Decision Making, Organizational↗
PubMed2005

Analysis of diagnostic error in paid malpractice claims with substandard care in a large healthcare system.

OBJECTIVE: Although claims databases are not representative of all care delivery, their predisposition toward serious unintended injury can complement resource-intensive chart reviews and guide patient safety initiatives. MATERIALS AND METHODS: Non-Veterans Health Administration (VA) practitioners reviewed 1,949 VA malpractice claims paid during fiscal years 1998 through 2003. The portion associated with substandard care, the severity of harm, and types of negligence were identified. RESULTS: Negligent adverse events occurred in 37% (n = 723) of paid VA malpractice claims. These had high proportions of serious injury (55%) and morbidity (37%). Diagnostic negligent adverse events were most frequent (45%) and with 41% associated morbidity. The annual incidence of diagnosis-related paid VA malpractice claims was 1.95 per 100,000 patients and predicts that 122 of every 100,000 patients may have diagnostic negligent adverse events. Comparisons against non-VA data suggest this to be a healthcare industry problem. CONCLUSIONS: Diagnosis-related negligent adverse events are a serious problem in the healthcare industry.

Diagnostic Errors↗
PubMed2006

Comparison of methodologies for calculating quality measures based on administrative data versus clinical data from an electronic health record system: implications for performance measures.

New reimbursement policies and pay-for-performance programs to reward providers for producing better outcomes are proliferating. Although electronic health record (EHR) systems could provide essential clinical data upon which to base quality measures, most metrics in use were derived from administrative claims data. We compared commonly used quality measures calculated from administrative data to those derived from clinical data in an EHR based on a random sample of 125 charts of Medicare patients with diabetes. Using standard definitions based on administrative data (which require two visits with an encounter diagnosis of diabetes during the measurement period), only 75% of diabetics determined by manually reviewing the EHR (the gold standard) were identified. In contrast, 97% of diabetics were identified using coded information in the EHR. The discrepancies in identified patients resulted in statistically significant differences in the quality measures for frequency of HbA1c testing, control of blood pressure, frequency of testing for urine protein, and frequency of eye exams for diabetic patients. New development of standardized quality measures should shift from claims-based measures to clinically based measures that can be derived from coded information in an EHR. Using data from EHRs will also leverage their clinical content without adding burden to the care process.

Blood Pressure↗
PubMed2004

Independent medical review: expanding legal remedies to achieve managed care accountability.

Author Leatrice Berman-Sandler reports on independent medical review (IMR), a state-based statutory remedy used to resolve disputes over coverage between patients and their health plans. Ms. Berman-Sandler explores the connection between ERISA preemption and IMR, and opines that in light of recent Supreme Court decisions, the stage has been set for expansion of IMR. Accordingly, Ms. Berman-Sandler concludes that there are strong legal and policy reasons for state legislatures to broaden the application of IMR and for the Court to continue to narrow ERISA preemption in order to increase accountability in the managed care arena.

Employee Retirement Income Security Act↗
PubMed2005

The polyp detection rate of colonoscopy: a national study of Medicare beneficiaries.

National-level data on the proportion of colonoscopies in routine practice that result in polyp detection are limited. Our goal was to determine the diagnostic yield of colonoscopy among population subgroups. We reviewed Medicare claims data for all fee-for-service beneficiaries 65 years or older who underwent colonoscopy in 1999. With the use of diagnosis and procedure codes, the proportion of procedures with polyps was estimated. Three different criteria for polyp detection were used. Approximately 1.8 million colonoscopy procedures were identified. Depending on the specific criteria used, 23.9% to 35.7% of examinations noted polyps. The detection rate was highest in younger patients, men, and whites. The apparent yield of colonoscopy in terms of polyp detection is at least 24%. These data may be informative in predicting resource allocation for therapeutic procedures associated with colonoscopy. Future studies should determine the use and yield of serial colonoscopies for polyp surveillance.

Age Factors↗
PubMed1995

Primary care, avoidable hospitalization, and outcomes of care: a literature review and methodological approach.

The purpose of this article is to review the literature on the relationships between primary care, potentially avoidable hospitalizations, and outcomes of care and to develop a methodology to study these relationships. The methodological approach includes developing criteria to select medical conditions, aggregating patient claims files of both ambulatory and acute care records, and delineating episodes of care. A taxonomy of physician visits is proposed that classifies visits on the basis of type of care, type of illness, and linkage to hospital episodes. A structural model of use and outcomes is specified that includes hazard rate models to estimate the likelihood of a potentially avoidable hospitalization, primary care and ad hoc physician visits, and mortality; the latter suggests a modification of the Health Care Financing Administration methodology that includes physician visit variables.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2006

Using predictive modeling to evaluate the financial effect of disease management.

The objective of this study was to use predictive modeling to evaluate a disease management (DM) program's effect on a chronically ill population. Specifically, diagnostic cost grouping (DCG) predictive modeling was utilized to measure the financial effect of DM in populations of individuals with congestive heart failure and coronary artery disease. The literature of current practices regarding DM's financial effect measurement was reviewed and critiqued--especially with reference to the population-based pre-post method. The time period for the present study is three years, and the variables of interest are financial metrics. Claims data and DM program-specific data covering the 24-month period of 2001 to 2002 and the 24-month period of 2002 to 2003 were analyzed. The mean differences between DCG predicted and actual total claims costs in 2002 and in 2003 were computed. Inflation factors, based on actual health plan population experience for the populations in question, were developed and applied to accurately evaluate financial effect. The preliminary findings suggest that a study design utilizing DCG predictive modeling in evaluating DM program financial impact provides more accurate results compared with the population-based pre-post method currently favored by DM companies.

Adolescent↗
PubMed1988

Hospital utilization review: past experience, future directions.

Utilization review (UR) programs seek to determine whether specific services are medically necessary and whether they are delivered at an appropriate level of intensity and cost. Although UR programs have been operating for more than 40 years, they have changed dramatically during the past two decades. Today, many health care providers, analysts, and policymakers view UR as a possible solution to hospital inpatient cost and quality problems. This paper addresses how UR has evolved, how UR is used today by different delivery mechanisms (i.e., Medicare, health maintenance organizations, preferred provider organizations, Blue Cross, and commercial insurers), the cost effects of various UR approaches, and how UR will be used in the future.

Blue Cross Blue Shield Insurance Plans↗