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PubMed2004

Impact on public hospitals if private health insurance rates in Victoria declined.

The additional cost of treating acute care type Victorian private patients as public patients in Victorian public hospitals based on the current public sector payment model and rates was calculated, as was the loss of health fund income to public hospitals. If all private cases became public the net recurrent cost would be $1.05 billion assuming all patients were still treated. If private health insurance (PHI) uptake had declined to 23.3% as was projected without Lifetime Health Cover and the 30% rebate, the additional operating cost and income loss would be $385 million. This compares to the Victorian cost of the 30% rebate for acute hospital cases of $383 million. This takes no account of capital costs and possible public sector access problems. The analysis suggests that 31 extra operating theatres would be needed in the public sector (had the transfer of surgical patients from the public sector to the private sector not occurred). This analysis suggests that without the PHI rebate the current stresses on Victorian public hospitals would be increased, not decreased.

Hospital Costs↗
PubMed2003

Assessing the validity of insurance coverage data in hospital discharge records: California OSHPD data.

OBJECTIVE: To assess the accuracy of data on "expected source of payment" in the patient discharge database compiled by the California Office of Statewide Health Planning and Development (OSHPD). DATA SOURCES: The OSHPD discharge data for the years 1993 to 1996 linked with administrative data from the University of California (UC) health benefits program for the same years. The linked dataset contains records for all stays in California hospitals by UC employees, retirees, and spouses. STUDY DESIGN: The accuracy of the OSHPD data is assessed using cross-tabulations of insurance type as coded in the two data sources. The UC administrative data is assumed to be accurate, implying that differences between the two sources represent measurement error in the OSHPD data. We cross-tabulate insurance categories and analyze the concordance of dichotomous measures of health maintenance organization (HMO) enrollment derived from the two sources. PRINCIPAL FINDINGS: There are significant coding errors in the OSHPD data on expected source of payment. A nontrivial percentage of patients with preferred provider organization (PPO) coverage are erroneously coded as being in HMOs, and vice versa. The prevalence of such errors increased after OSHPD introduced a new expected source of payment category for PPOs. Measurement problems are especially pronounced for older patients. Many patients over age 65 who are still covered by a commercial insurance plan are erroneously coded as having Medicare coverage. This, combined with the fact that during the period we analyzed, Medicare HMO enrollees and beneficiaries in the fee-for-service (FFS) program are combined in a single payment category, means that the OSHPD data provides essentially no information on insurance coverage for older patients. CONCLUSIONS: Researchers should exercise caution in using the expected source of payment in the OSHPD data. While measures of HMO coverage are reasonably accurate, it is not possible in these data to clearly identify PPOs as a distinct insurance category. For patients over age 65, it is not possible at all to distinguish among alternative insurance arrangements.

California↗
PubMed2000

Rates of hospitalization for asthma by insurance status.

OBJECTIVE: To compare utilization of emergency department (ED) and inpatient resources for asthmatics across insurance types. METHODS: Retrospective cohort analysis consisting of patients over 18 years of age admitted to the ED of 27 hospitals located throughout the United States for asthma between October 1, 1996 and September 30, 1997. RESULTS: 2738 patients were identified who met all inclusion/exclusion criteria. Approximately 25% of the sample had traditional indemnity insurance, 22% were managed care enrollees, 35% were enrolled in Medicaid or Medicare, and 18% were self-pay. Cost of treatment varied by insurance type in the ED and for inpatient asthma care: Medicare patients tended to have higher ED costs than all other insurance types, while indemnity patients had higher costs than Medicaid and Medicare patients. No significant differences were observed between managed care or indemnity patients for ED or inpatient costs; however, indemnity patients were less likely to be hospitalized for asthma subsequent to visiting the ED than managed care patients (OR: 0.40, 95% CI: 0.31-0.52). CONCLUSION: Significant differences in types and costs of care were observed across differing insurance types, which may suggest an "insurance effect" on asthma-related treatment in the ED and/or hospital.

Adolescent↗
PubMed1982

Changing the rules of the reimbursement game.

Recently enacted federal and state legislation reflect a gradual transition from cost-based reimbursement to rate-based reimbursement for hospital services; the implications of this trend for hospital pharmacists are discussed. Under "The Tax Equity and Fiscal Responsibility Act of 1982," Medicare hospital reimbursement is limited based on total hospital costs, effective for the 1983 fiscal reporting period. In addition, a target limit of costs for each hospital will be computed and hospitals will have positive and negative incentives to keep costs below this amount. These reimbursement changes calculate limits on the basis of costs per case, not costs incurred. These changes increasingly require hospitals to share in the risk of expenditures attributed to use of services. For hospital pharmacists, this means that the focus is changing from maximizing revenue from drug products to controlling unnecessary use and reducing departmental expense. Clinical pharmacy services will survive only if they are shown to be cost effective. Hospital pharmacists cannot afford to ignore the changing patterns of reimbursement; the consequences of unpreparedness and inaction may be decreased budgets and the relegation of hospital pharmacy practice to assembly-line economics.

Insurance, Hospitalization↗
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↗