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PubMed2006

The big squeeze. Insurers point to slower growth in premiums in past few years to show progress, but providers say they're paying the price.

While insurers last week were trumpeting the third straight year of slower growth in premiums, providers weren't exactly celebrating. That's because of huge mergers, which give insurers far more leverage and have led to reimbursements being cut back even more. "What's worrying us is that there's a growing segment (of insurers) that aren't going to budge an inch, no matter what," says Russ Weaver, left.

Cost Savings↗
PubMed1992

Home oxygen therapy under Medicare. A primer.

Medicare recently implemented a new, strict, and complex home oxygen policy and a new oxygen prescription form. Unfortunately, the lack of instructions for the form has led to confusion, frustration, and suboptimal treatment. Long-term oxygen therapy prolongs survival, ameliorates hypoxic organ dysfunction, and improves exercise endurance. Indications for therapy include hypoxemia caused by cardiopulmonary diseases, hypoxemia that occurs with sleep or exercise, and hypoxemic organ dysfunction. Patients should be stable and have an arterial blood oxygen tension (PaO2) of 55 mm of mercury (7.3 kPa) or less or arterial blood oxygen saturation (SaO2) of 88% or less. There should be evidence of hypoxic organ dysfunction when the (PaO2) is 56 to 59 mm of mercury (7.4 to 7.8 kPa) or the SaO2 is 89%. A medical review by the insurance carrier is required if oxygen is to be prescribed when hypoxemia is less severe--if the PaO2 is 60 mm of mercury (8.0 kPa) or more or if the SaO2 is 90% or more. The instructions for oxygen flow, duration, and equipment must be explicit to ensure adequate therapy. An oxygen concentrator with a small oxygen cylinder portable system fulfills most needs. Oxygen cylinders may be used at low flows for patients who require therapy only during sleep or where electrical power is unreliable. A liquid oxygen system may be prescribed for active patients. Portable equipment should be provided in addition to stationary equipment when patients have resting hypoxemia. Portable equipment alone is sufficient when there is exercise-related hypoxemia with normal oxygenation at rest. Newly developed oxygen-conserving devices may offer longer ambulatory times and possibly lower operating costs. When home oxygen therapy is started in the hospital, the Certificate of Medical Necessity should be completed and patients should be trained to use the equipment before discharge.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

[Legal code for public health physicians and compensation].

The complete, updated laws governing doctors subject to the National Health Insurance System are to be found in volume V of the Social Legislation Statutes which went into effect on 1 January 1989. In this work there ist a description of the structure and the mission of the Association of National Health Insurance Doctors and of the Medical Board. Claims für services rendered by doctors are to be forwarded to the Association for collection from the insurance carriers. To monitor said services both financial and technical control procedures have been established by the Association. Medicines prescribed by the doctors are also subject to control by the carriers and/or a commission of the Association to ascertain whether a medicine prescribed is the most appropriate for the particular situation and whether such medicine is really required in said situation.

Fees, Medical↗
PubMedDate not supplied

Impact of fraudulent claims on health care costs.

The U.S. health care system, considered one of the best in the world for technological sophistication and availability of services, is being seriously threatened by continually escalating costs. Although there are many reasons for this, fraud within the industry accounts for 10 percent of the nation's annual health care bill. By the end of the decade, the fraud factor may cost the industry $160 billion a year. Health insurers and state and government agencies are joining forces to share information and intensify their efforts in the battle against fraud. MetLife's in-house efforts include a specialized unit devoted entirely to the prevention, detection and prosecution of fraud. In 1990 the company's vigilance saved its policyholders over $38 million.

Data Collection↗
PubMedDate not supplied

Charges for substance abuse hospitalization: regional variations, 1990.

MetLife 1990 group health insurance costs for a substance abuse hospitalization averaged $7,660. The highest average total charges were reported in Texas and New Mexico, each with costs 30 percent or more above the U.S. average. The lowest average costs (those more than 30 percent below the norm) were reported in Oregon, Iowa, Minnesota and Massachusetts. Physician charges comprised less than 10 percent of the average total charges. Ancillary fees ranged from 6 percent of the hospital portion of the bill in Montana to 41 percent in Texas.

Ancillary Services, Hospital↗
PubMed1991

Demonstration of SLUMIS: a clinical database and management information system for a multi organ transplant program.

Because of the rapid evolution of the heart, heart/lung, liver, kidney and kidney/pancreas transplant programs at our institution, and because of a lack of an existing comprehensive database, we were required to develop a computerized management information system capable of supporting both clinical and research requirements of a multifaceted transplant program. SLUMIS (ST. LOUIS UNIVERSITY MULTI-ORGAN INFORMATION SYSTEM) was developed for the following reasons: 1) to comply with the reporting requirements of various transplant registries, 2) for reporting to an increasing number of government agencies and insurance carriers, 3) to obtain updates of our operative experience at regular intervals, 4) to integrate the Histocompatibility and Immunogenetics Laboratory (HLA) for online test result reporting, and 5) to facilitate clinical investigation.

Academic Medical Centers↗
PubMed1991

How profitable is medical malpractice insurance?

High medical malpractice insurance premiums charged to physicians have created the perception of a crisis. Some researchers have expressed the concern that medical malpractice insurance companies are making excessive profits. In this paper I compute the actual and allowable normal underwriting profit rates in medical malpractice, as well as in other liability lines, for six large insurance companies. These allowable, normal profit rates are then compared with actual profit rates to evaluate the relative profitability of each line of insurance. Data from 1978 through 1986 show that medical malpractice insurance ranked medium in underwriting profitability compared with other lines of insurance, and during 1985-86 it was the least profitable insurance business.

Actuarial Analysis↗
PubMed1991

Failed back surgery syndrome.

The failed back or postlaminectomy syndrome is obviously multidimensional. Failure of therapy may result from structural abnormalities in the back, psychosocial influences, or a combination of both. The causes of back pain are largely unknown. Correlations with diagnostic studies are uncertain. The lack of precise diagnoses is reflected in a multiplicity of nonspecific treatments, mostly of unproven value. Our current disability-litigation system adds greatly to the problem. Patients are rewarded for nonfunction. Some physicians become advocates for patients, others for insurance carriers and employers. Decisions concerning appropriate treatment are often made by patients, attorneys, the disability determination system, employers, and judges for extraneous reasons, which include financial gain or personal bias and often reflect lack of current information. Even when correct decisions are made, there is a lack of adequate programs for diagnosis and comprehensive treatment of these individuals. The failed back syndrome is not likely to disappear quickly. Large numbers of these patients require care. The best available evaluation includes thorough, but not overly minute investigation using the best current imaging techniques. These studies combined with the history and physical examination should provide a reasonably accurate assessment of the patient's condition. Concomitant evaluation of psychosocial issues is mandatory, and those who treat these patients without understanding the importance of the various comorbidities discussed are likely to be detrimental. Reparative surgery has real, but limited use. Nerve root compression and instability are the only two conditions demonstrated to be correctable at the present time. However, even when a potentially remediable lesion is found, these patients should undergo a reasonable attempt at physical rehabilitation with attention to both local factors and general function. The best data available today suggest that most of the patients suffering from failed back syndrome are incapacitated by psychiatric, psychologic, and social/vocational factors, which relate to the back complaint only indirectly. Those currently suffering from this problem can be best treated by comprehensive programs that address these complex psychosocial issues. New additions to this category can be reduced by rigorous attention to physical abnormalities, so that surgery is undertaken only for clear indications, and appreciation of the importance of the psychologic aspects of disability from low back pain. The smaller group suffering principally from physical abnormalities can be improved by reparative surgery or pain-relieving procedures if intensive conservative rehabilitation efforts fail. All surgical procedures fail occasionally, and as long as there is a need for reparative surgery, some patients will fail to benefit or be worsened by the procedures.(ABSTRACT TRUNCATED AT 400 WORDS)

Back Pain↗