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PubMed1992

Costs and coverage. Pressures toward health care reform.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.

Delivery of Health Care↗
PubMed1983

The effect of case-mix adjustment on admission-based reimbursement.

This paper addresses two questions: (1) Does adjusting for case mix have any effect on prospective admission-based reimbursement? and (2) How does the way in which case type is defined (DRG, ICD9CM, Age, etc) affect reimbursement systems? Data from 20 Maryland hospitals provided the basis for analysis, and the results illustrate how hospital reimbursement is affected under alternative definitions of case type (including no case type), showing highly significant variation. Implications for cost control and existing and proposed prospective reimbursement systems are discussed.

Costs and Cost Analysis↗
PubMed2001

Reliability of optimal control strategies for photochemical air pollution.

This study illustrates how consideration of modeling uncertainties can affect optimal control strategies for urban ozone. Control strategies are investigated for illustrative cases of air parcel trajectories ending at Azusa, CA, and Riverside, CA, on August 28, 1987. The control strategies are designed to achieve a specified air quality target with a given reliability, considering uncertainties in the California Institute of Technology's trajectory model and its inputs, including uncertainties in emissions and in the SAPRC-97 chemical mechanism. A decoupled stochastic optimization scheme is used to solve the chance-constrained programming problem. Least-cost control strategies derived using nominal model inputs and parameter values have low reliability for some target O3 concentrations when uncertainties are taken into account. For the case considered, reducing volatile organic compound (VOC) emissions from motor vehicles is identified as the least-cost approach to meeting O3 targets at Azusa. However, the optimal control strategies for Riverside depend on the target O3 concentrations and the level of reliability required. Consideration of model uncertainty is found to shift the focus from VOC controls to nitrogen oxide controls for the Riverside trajectory.

Air Pollution↗
PubMed2004

Costs attributable to AIDS at household level in Chad.

This paper assesses the economic costs of AIDS at the household level in Chad, one of the poorest countries in the world. One hundred and ninety-three AIDS patients living in four different regions were found by case identification at hospital level and through community based organizations providing psycho-social relief. They were matched by age, sex, professional category and zone of residence with controls. Costs were evaluated through a standard questionnaire. Costs at household level attributable to AIDS up to death were US$836 per case. Costs related to productivity losses made up 28% of total costs. More than half of total costs (56%) were health care related expenditures and funeral costs contributed 16%. AIDS cases relied more often on borrowing and the selling of household assets than controls for treatment. Household expenditures of AIDS cases were much higher than control households mainly due to health related expenditure. The response of concerned families to HIV/AIDS implies high costs and for most households, especially in low-income settings, the consequences of AIDS are devastating. Innovative strategies on how best to assist households are thus requested and may include the strengthening of care and treatment services being offered to AIDS cases.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Activity-based cost management in health care--another fad?

By providing improved information for strategic planning purposes activity-based cost management (ABM) systems can help hospitals and other health care providers improve the quality and efficiency of the care they provide control costs and manage their resources better. The NHS is starting to evaluate the ABM approach. Describes a research project in one specialist hospital in Sheffield UK which found that conventional approaches to costing can be inaccurate by as much as 100 per cent; conventional approaches will consistently undercost complex, specialist, infrequent episodes of care and overcost straightforward frequent episodes; and the resulting information from ABM about costs and processes significantly improves the decision-making capabilities of managers particularly in relation to ¿what if¿ situations.

Cancer Care Facilities↗
PubMed1996

Health care reforms and managed care for substance abuse services: findings from eleven case studies.

In 1992, the United States spent $820 billion on health care. For the same year, an estimated 15 percent of the U.S. population, approximately 43 million people, were uninsured. As health care costs continue to rise, the number of people able to afford coverage continues to decline. Given these statistics, it is not surprising that concern over health care reform is at the forefront of government policy. Over the past few years, policymakers have faced the challenge of creating a more cost-efficient, universal health care system. Many of the proposed reforms rely heavily on managed care practices and treatment limits to help control costs. The impact of managed care is already apparent in primary health care where private insurers have been using it for years (e.g., HMOs, PPOs). However, its full impact on substance abuse treatment services remains unknown. In this paper, we present the perceptions, opinions, and experiences of eleven drug treatment programs regarding the actual or anticipated effects of managed care and health care reforms on the delivery, financing, and costs of substance abuse treatment. We also present an analysis of these programs' current costs and financing. We believe that the information presented in this paper provides timely insights into the substance abuse treatment system; these insights should assist policymakers in developing optimal health care reform policies.

Cost-Benefit Analysis↗
PubMed1994

[The cost of primary health care. Administrative prices versus real costs].

The income source and the use of assets at the Health Department of a Chilean city hall was studied. A cost control system was created to know the real value of health services, which were compared with the administrative tariffs determined by the authorities. Specific health programs such as complementary feeding, immunizations and responsible paternity programs represented 48.1% of the Health Department expenses. Ninety four percent of services had a real cost that exceeded their administrative price. A reformulation of resource distribution for primary health care and the development of control systems that measure the results of experience activities is proposed.

Chile↗
PubMed1984

Reducing prescribing costs through computer controlled repeat prescribing.

A small reduction in prescribing costs is reported from a general practice that has been using a computer for repeat prescribing for three years. The possible reasons for this are discussed. The information available from the Prescription Pricing Authority (PPA) and from practice workload measurements was found to be inconclusive. An elaboration of the computer-controlled system of repeat prescribing to provide a detailed cost analysis of this aspect of prescribing was devised, and the first results are presented. It is calculated that 27 per cent of prescriptions in the practice are produced from electronic records and that the average cost of these is not significantly greater than for prescriptions issued in other situations.

Computers↗
PubMed2006

Estimated direct economic costs associated with tick-borne diseases on cattle in Tanzania.

Tick-borne diseases, namely, anaplasmosis, babesiosis, cowdriosis and theileriosis, constrain cattle production and improvement in Tanzania, leading to considerable economic losses. A simple spreadsheet model was used to estimate the economic losses resulting from production losses, treatment and control costs associated with tick-borne diseases (TBD) in Tanzania. Model parameters included the national cattle population, reported TBD morbidity, fatality risk, and chemotherapy and control measures used. The total annual national loss due TBD was estimated to be 364 million USD, including an estimated mortality of 1.3 million cattle. Theileriosis accounted for 68% of the total loss, while anaplasmosis and babesiosis each accounted for 13% and cowdriosis accounted for 6% of the total loss. Costs associated with mortality, chemotherapy and acaricide application accounted for 49%, 21% and 14% of the total estimated annual TBD losses, respectively, infection and treatment method milk loss and weight loss accounted for 1%, 6% and 9% of the total annual loss, respectively. Despite the inadequacies of the data used, the results give evidence that tick-borne diseases inflict substantial economic losses on cattle production and resource use in Tanzania.

Anaplasmosis↗
PubMed1995

Infection control programmes--are they cost-effective?

Infection control (IC) programmes are cost-effective in the long-term but much depends on the available resources and the support from management. The funding of IC programmes at present is linked to the Microbiology Department and a separate budget needs to be established. The best use of resources is to apply a risk assessment to each situation which presents and to adapt protocols accordingly. For example, the treatment of a carrier or an infected patient with methicillin-resistant Staphylococcus aureus cost 374 pounds and 2454 pounds, respectively in 1993, the major portion of the cost being due to an increased length of stay which was two days and 10 days, respectively. It is more cost-effective to treat carriers. The other cost-effective investment is in education and reinforcement of simple messages. Formal lectures seem to be the least effective way of producing long-term effect; frequent ward visits or contacts are most effective. Also, there is better compliance when there is a perceived risk to the staff themselves. The availability of the IC team to advise helps reduce waste and therefore cost. This is particularly true of antibiotic usage where it was noted that without guidance, the antibiotic usage increased by 2000 pounds per month when compared to a similar period in the previous year. The available provisions for IC programmes in the UK are utilized exceptionally well when compared with other countries.

Anti-Bacterial Agents↗
PubMed2007

Health systems in East Asia: what can developing countries learn from Japan and the Asian Tigers?

The health systems of Japan and the Asian Tigers (Hong Kong, Korea, Singapore and Taiwan), and the recent reforms to them, provide many potentially valuable lessons to East Asia's developing countries. All five systems have managed to keep a check on health spending despite their different approaches to financing and delivery. These differences are reflected in the progressivity of health finance, but the precise degree of progressivity of individual sources and the extent to which households are vulnerable to catastrophic health payments depend on the design features of the system - the height of any ceilings on social insurance contributions, the fraction of health spending covered by the benefit package, the extent to which the poor face reduced copayments, whether there are caps on copayments, and so on. On the delivery side, too, Japan and the Tigers offer some interesting lessons. Singapore's experience with corporatizing public hospitals - rapid cost and price inflation, a race for the best technology, and so on - illustrates the difficulties of corporatization. Korea's experience with a narrow benefit package illustrates the danger of providers shifting demand from insured services with regulated prices to uninsured services with unregulated prices. Japan, in its approach to rate setting for insured services, has managed to combine careful cost control with fine-tuning of profit margins on different types of care. Experiences with DRGs in Korea and Taiwan point to cost-savings but also to possible knock-on effects on service volume and total health spending. Korea and Taiwan both offer important lessons for the separation of prescribing and dispensing, including the risks of compensation costs outweighing the cost savings caused by more 'rational' prescribing, and cost-savings never being realized because of other concessions to providers, such as allowing them to have onsite pharmacists.

Delivery of Health Care↗
PubMed2000

Better Medicare Cost Report data are needed to help hospitals benchmark costs and performance.

To evaluate costs and achieve cost control in the face of new technology and demands for efficiency from both managed care and governmental payers, hospitals need to benchmark their costs against those of other comparable hospitals. Since they typically use Medicare Cost Report (MCR) data for this purpose, a variety of cost accounting problems with the MCR may hamper hospitals' understanding of their relative costs and performance. Managers and researchers alike need to investigate the validity, accuracy, and timeliness of the MCR's cost accounting data.

Accounting↗
PubMed1978

One approach to building an HSA data base.

This paper discusses one approach for Health Systems Agencies to focus their information acquisition and analysis activities on subjects which will be most helpful to them in gaining visibility and credibility, while also offering opportunities for identifying and quantifying the most serious problem confronting them--the rapid rise in health care expenditures. Assembling information on health care expenditures will have the additional benefit of allowing the planning agencies to isolate and monitor the possible effects which their actions may have on changes in health care costs. This may become particularly critical in a few years when the Congress and HEW are less patient and more insistent that evidence of clear cost control benefits will have to be produced if the nation is to continue to invest in health planning. In general, as health care costs have continued to climb, serious questions have been raised about the ability of the taxpayers, employees, and employers, through insurers, to continue to pay for even the health services and benefits now available. At a minimum, severe fiscal pressures will seriously threaten existing entitlements and coverage. Health planning could be a major tool to reduce cost inflation and protect other social and health programs while simultaneously permitting the introduction of needed and desirable innovations. Health planning could be a significant instrument for shifting health system investments, especially capital investments, into those areas which may produce more health at the margin than current expenditures.

Health Expenditures↗
PubMedDate not supplied

[The quality assessment from the minimum basic hospital discharge data set].

INTRODUCTION: Risk adjustment is essential before comparing patient outcomes across hospitals. With this aim several risk adjustment systems have been developed, including the well-known diagnosis related groups. MATERIAL AND METHODS: Narrative review on risk assessment framework from administrative databases, including data quality and system pitfalls. RESULTS: The risk adjustment systems developed for cost-control aims to group different patient typologies in relation to the predicted use of resources with the aim to develop incentives to cost-reduction; the systems developed for measuring effectiveness have the objective to assess the health care quality. Both systems are useful for clinical, management and health public uses, but they have several pitfalls and their results should be interpreted cautiously. CONCLUSIONS: Managers and physicians should consider the risk adjustment systems as a valuable resource for decision-making and reducing uncertainty, but not as the scientific referee of hospital quality or hospital efficiency.

Cost-Benefit Analysis↗
PubMed1982

Quality measurement and control in physician decision making: state of the art.

The status of the concept of controlling the quality of physicians is reviewed as are studies that have been done on methods to measure and improve quality. The conclusions are dismal given the rhetoric and actions on attempts to measure and control quality of physician decision making. Massive attempts are being made, for example, mandating PSROs to monitor quality before there is a methodology. Cost and quality reviews have, at most, a marginal impact and do not deserve the expenditures to conduct them. Studies on utilization review show minimal impact on reducing utilization. Administrative reviews reduce utilization for certain specific, narrowly defined procedures such as injections. There is no operational definition of "unnecessary" utilization. The tendency is to regard the lowest levels as optimal, presumably because they result in lower expenditures. Bureaucratic reviews do not provide incentives to decision makers the way various types of HMO delivery types do from current evidence. Hence, HMOs, deductibles and coinsurance, and competition have greater promise for limiting expenditures than do utilization reviews. Quality audits are also marginally effective because of limited promise of changing provider behavior given current methods of doing so. They miss the organizational aspects in which incentives are generated. Research is needed, therefore, on alternative forms of quality and cost control such as HMOs, physician risk sharing, competitive models, and deductibles and coinsurance. Until the much needed research has been done, the amount of resources spent on review should be minimized. In the meantime, the review processes should concentrate on extreme variations of very narrowly defined criteria of proven validity while improving the review methodology by systematic research on quality monitoring.

Decision Making↗
PubMedDate not supplied

Cost-effective quality assurance of rented medical equipment.

The Biomedical Engineering Department (BME) at the University Medical Center, Tucson, Arizona, noted a sharp increase in the use of rented medical equipment. To increase efficiency, control costs, and provide effective quality assurance for rented equipment, a Medical Equipment Rental Vendor (MERV) program was formulated. The program increases efficiency by placing the burden of verifying safety and performance on the MERVs. Performance requirements were developed for the MERVs. The vendors who agreed to the requirements were compiled into a list of preferred vendors to be the primary suppliers of rental medical equipment to UMC. These preferred vendors were given preapproval from BME to deliver equipment directly to the requesting clinical department. All other vendors must continue to submit their equipment to BME for inspection. Policies were written to outline the responsibilities of the clinical departments and BME relative to the MERVs. Frequency of sampling, means of documentation, and assurance of user training were included. Response from the vendors and clinical departments has been positive. Communication between the vendors, clinical departments, and BME has improved through the development and implementation of this program. Vendor and equipment quality have been maintained or improved since compliance with the performance requirements is necessary to maintain preferred vendor status.

Arizona↗
PubMed1978

Physician responsibility for the cost of unnecessary medical services.

Most diagnostic and therapeutic services are ordered by physicians, but physicians practicing under fee-for-service conditions have few incentives to contain the costs of medical care. Without such incentives, effective cost control through mechanisms such as Professional Standards Review Organizations have been disappointing. Several legal approaches might be used to increase physicians' responsibility for the cost of unnecessary services--expansion of tort law, implied contact, redesign of insurance mechanisms, equitable estoppel and informed consent. However, increasing physician responsibility will require uniform but flexible definitions of medical necessity, reliable means for predeterming the need for services and effective penalties or incentives. We propose a peer-review system that would incorporate the sharing of financial risk among physician, hospital, insurer and patient in the fee-for-service sector.

Costs and Cost Analysis↗