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PubMedDate not supplied

Variations in healthcare measures by insurance status for patients receiving ventilator support.

OBJECTIVE: To examine differences in healthcare delivery by expected health insurance status for hospitalized patients in diagnosis-related group (DRG) 475, respiratory system diagnoses requiring intubation and continuous ventilator support. DESIGN: A survey, derived from the Healthcare Cost and Utilization Project interstate database, of the care delivered to 21,149 adult patients in DRG 475 and hospitalized in one of 718 acute-care hospitals in nine states. Multivariate analysis was performed, controlling for demographic and hospital factors. RESULTS: Patients insured by health maintenance organizations (HMOs) had significantly lower rates of inpatient mortality (odds ratio [OR], 0.84; 95% confidence interval [CI95], 0.73-0.96), 14.3 more procedures performed (CI95, 11.5-17.2), 7.0% shorter hospitalizations (CI95, 12.5-1.6), and 5.2% higher charges (CI95, 0.4-10.0) than those with traditional private insurance. In addition, patients insured by Medicaid had 3.5% more procedures performed (CI95, 1.6-5.4), 10.4% longer lengths of hospitalization (CI95, 6.7-14.0), and 13.8% higher charges (CI95, 10.6-17.0) than those with traditional private insurance. Finally, the uninsured had significantly lower rates of inpatient mortality (OR, 0.87; CI95, 0.77-0.99), 8.5% more procedures performed (CI95, 6.0-11.1), 16.5% shorter hospitalizations (CI95, 21.5-11.6), and 13.4% lower charges (CI95, 17.8-9.0) than those with traditional private insurance. CONCLUSION: Variations in healthcare measures by insurance status for this DRG emphasize the importance of more careful analyses of insurance categories as a determinant of healthcare access and outcomes. Expected insurance status was an independent predictor of cost. Private insurance and HMO populations differed significantly in outcome and cannot be considered equivalent.

Adolescent↗
PubMed2006

Getting your game on with business data.

Data warehouses can virtually eliminate claims-related paper and fax transactions for hospitals. Data are accessible electronically, decreasing the need for staff to check on outstanding claims status requests by phone. Data warehouse technology can be used to create analytical reports and identify issues by dollar volume or procedure code. Providers can receive instant reports on both the "front end," as they are submitted, and on the "back end," when claims are denied.

Database Management Systems↗
PubMed1990

Biased selection under the senior health plan prior use capitation formula.

A widely acknowledged shortcoming of the current AAPCC capitation formula for Medicare HMOs is its inability to adjust capitation levels for differences in health status among enrolled groups. Prior use models have been proposed as one alternative to the current AAPCC risk classes. From 1984 through 1987, Senior Health Plan (SHP) participated in a HCFA-sponsored demonstration project in which capitation payments were determined by a prior use formula incorporating information on inpatient hospital days and Part B deductibles. This paper contains findings about selection bias in SHP enrollment from analyses of preenrollment reimbursements and postenrollment mortality rates of SHP enrollees compared with Medicare FFS beneficiaries and enrollees of other Medicare HMOs in the Minneapolis-St. Paul area.

Capitation Fee↗
PubMed1989

Collecting from third-party payers.

Self-pay collections and insurance collections are similar. Phone the insurance company, obtain a firm payment date, and follow up when payment is not received. Be organized and persistent. Don't hesitate to contact the patient for help. This is the patient's bill that you are trying to collect. You are working on his behalf but the patient is ultimately responsible for payment. The bottom line in third-party collection is phone contact and persistence.

Accounting↗
PubMedDate not supplied

Connections to primary medical care after psychiatric crisis.

BACKGROUND: Patients presenting with a psychiatric emergency face a unique set of challenges in connecting to primary care. OBJECTIVES: We tested the hypothesis that, in contrast to usual care, case management will result in higher rates of connection to primary care. We examined variables affecting primary care entry, including insurance status, hospital admission, and concurrent linkages to mental health care. RESEARCH DESIGN/METHODS: This article reports on a preliminary outcome of an ongoing randomized controlled trial conducted with 101 patients presenting in an urban psychiatric setting. Patients were randomized to a case management team or to usual care. The need for medical care was assessed by documenting medical comorbidity. RESULTS: Average age of the sample was 37.5; 65% were male, and 78% had low income; 37% were African American and 9% were Hispanic. Within 3 months of study enrollment, 57% of the intervention group was successfully linked to primary care compared with 16% of the usual care group, a difference that was statistically significant (P < .001). Associated positive predictors for linkage to primary care included mental health care visits and success in obtaining health insurance. Inpatient hospital stay at the time of psychiatric crisis was negatively associated with later attendance at primary care. CONCLUSIONS: Case management intervention was effective in establishing linkage to primary care within 3 months. Ongoing work will evaluate primary care retention and physical and mental health outcomes.

Adult↗
PubMed1994

[A table for converting ICD-9 to ICPC. A common platform for health insurance statistics for primary health care and hospitals, outpatient clinics and specialists' practices].

In 1992 Rikstrygdeverket decided that the analysis of billing systems and certificates of illness issued by the primary and secondary health care services should be based on ICPC. All general practitioners are expected to use ICPC-codes. Doctors working in hospitals and other specialists have already used the ICD-9 classification for many years and did not want to have to use two different encoding systems. To obtain a common platform for statistical analysis, a referral system was necessary to convert ICD-9 codes to corresponding ICPC codes. In this article, the head of project discusses the material and methods used in this project, and summarizes the results and the structure and formats of the referral table. The author also briefly discusses the potentials and limitations when diagnostic codes are converted from ICD-9 to ICPC.

Ambulatory Care Facilities↗
PubMed1985

The dominant firm in health insurance.

Blue Cross, the largest insurer of hospital costs in most parts of the U.S., has a varying market share by area. This paper examines the factors affecting the market share of Blue Cross by state. The regression analysis finds that the Blue Cross discount has an important impact upon market structure and that certain regulatory factors have had an impact while others, such as the premium tax, have not. Hypotheses related to the effects of consumer demand and the structure of the industry on Blue Cross market share are also tested and largely rejected.

Blue Cross Blue Shield Insurance Plans↗
PubMed1994

Health reform in Germany. An American assesses the new operating efficiencies.

In 1993, responding to a $5.7 billion deficit among the country's third-party payers, the German parliament imposed mandatory global budgets for physician, hospital, dental, and pharmaceutical services. Although Germany had been able to maintain health spending at a lower rate than the United States, an excessive supply of health resources was beginning to drive prices higher. During the three years the global budgets are in place, German third-party payers (the "sickness funds") and providers will implement several fundamental reforms. These include: Reducing excessive supply of specialists Constraining the acquisition and utilization of expensive medical technologies Reducing the annual number of physician visits per person Reducing average hospital length of stay Integrating community- and hospital-based physician services Reducing payroll deductions for mandated benefits The 1993 reforms also impose a budgetary cap at the 1991 expenditure level for drugs prescribed by community-based physicians. In addition, the reforms call for the implementation of community-rated premiums and stipulate that Germans be able to select their sickness fund each year. Although the reforms make important changes, they leave the basic German healthcare system intact. It is difficult to imagine, moreover, that any of the reforms being implemented will in the foreseeable future place any major element of the health system in serious financial peril; in fact, they will help preserve the system.

Budgets↗
PubMed1991

Comparing hospital length of stay in independent practice association HMOs and traditional insurance programs.

This study compares length of hospital stay in Independent Practice Association (IPA) HMOs and traditional insurance programs. Hospital admissions from 10 IPAs are compared with admissions to the same hospital of persons covered by Blue Cross and Blue Shield Plans or commercial insurance programs. Admissions of patients under age 65 to the adult medical service for the 10 most frequently occurring DRGs are included. Regression equations are estimated using length of stay as the dependent variable and IPA membership and hospital and patient characteristics as control variables. All 10 IPAs exhibit shorter lengths of stay as indicated by negative beta coefficients, and in 6 of the 10 IPAs this coefficient is statistically significant (p less than .05). This IPA effect occurs for 7 of the 10 study DRGs, and for MedisGroups Admission Severity Groups 0, 1, and 2.

Age Factors↗
PubMed2000

Hospital selection by managed care insurers.

This article focuses on which factors influence the ability of hospitals to attract managed care patients. Data for the analysis were obtained from a national sample of 235 acute care hospitals in 1996. The results indicate that the costs of inpatient care, participation in an integrated delivery system network, and hospital size were the critical factors in determining the ability of hospitals to obtain managed care business.

Data Collection↗
PubMed2001

Insurance status and admission to hospital for head injuries: are we part of a two-tiered medical system?

Previous studies have shown an association between insurance status and use of resources for inpatient care. We sought to assess whether insurance status influences decisions regarding the evaluation and treatment of head injured patients in the emergency department (ED). Head injured patients were identified from ED data from 4 hospitals reporting to the Kentucky Emergency Medical Services Information System. Multiple regression analysis using admission, ED length of stay, and ED charges as outcome variables was then performed. From 216,137 ED visits there were 8,591 (4%) head injured patients identified from the database. Eliminating those with revisits, transfers to another hospital in the database, and isolated facial lacerations, there were 3,821 cases. Controlling for age, hospital, race, primary diagnosis, and indicators of severity of the injury, insurance status was significantly associated with hospital admission. Those uninsured were the least likely to be admitted (OR 0.41; 95% CI (0.31, 0.50), whereas those with public insurance had an intermediate probability (OR 0.50 95% CI (0.37, 0.68) as compared with those with private insurance. Similarly, ED charges were lower for Medicaid patients than insured patients ($880) and tended to be slightly lower for uninsured patients ($1,043) than insured patients ($1,141) (P =.001). Length of stay in the ED was shorter for publicly insured patients (179 minutes) than uninsured (186 minutes) and privately insured patients (192 minutes) (P =.001). The extent of evaluation and admission for head injured patients is associated with insurance status. This creates a dual standard of care for patients. Practitioners should work to standardize the evaluation of patients independent of paying status.

Adolescent↗
PubMed1985

Variation in inpatient racial composition among acute-care hospitals in New York State.

This study examined the racial composition of inpatients among 282 short-stay, non-Federal hospitals in New York State. The primary data sources were two inpatient censuses conducted by Blue Cross in late 1975. These were augmented with data from the American Hospital Association's 1975 Annual Survey and the 1970 U.S. Census. Substantial disparity in racial mix was evident. Within New York City, for example, 24 out of 94 hospitals had fewer than 10% nonwhite patients, while 21 hospitals had 50% or more and 7 had 80% or more nonwhites. The proportion of patients covered by Medicaid was found by multiple regression analysis to be a major correlate of the proportion of patients who were nonwhite. Other factors positively associated with the proportion nonwhite included the proportion of patients admitted from the emergency room or outpatient department; presence of a residency program; and availability of family planning services. Analysis of two quality of care indicators revealed that, taking total patient load into account, hospitals with more nonwhite patients tended to have fewer nurses and total assets. In spite of nonwhite gains in access and utilization, the hospital system can still be characterized as 'separate and unequal'. It is suggested that a renewed effort to integrate health care facilities can have a positive impact on both majority and minority populations in this period of fiscal retrenchment.

Adolescent↗