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PubMed2003

Additional costs for preventing the spread of methicillin-resistant Staphylococcus aureus and a strategy for reducing these costs on a surgical ward.

OBJECTIVE: To determine the added costs of hygienic measures (barrier precautions, isolation, and decontamination) required for MRSA carriers in German hospitals and possible strategies for cost reduction. DESIGN: On a septic surgical ward caring for 35% of all MRSA cases in a university hospital (1,182 beds), additional costs for personnel time and materials were calculated and medical charts of all MRSA cases admitted to the ward during 1 year were analyzed retrospectively. Twelve of the ward's 13 beds were located in rooms with at least 2 beds. PATIENTS: Four hundred ninety-eight MRSA carrier hospital-days (of 20 MRSA cases) could be assessed. All patients (80% men, 50% older than 74.5 years) had broken skin. RESULTS: In 95% of the cases, microbiological findings suggested transmission of MRSA during the current or a previous stay on this ward. The study found total avoidable costs of approximately 142,794.01 euros in 1 year, averaging 371.95 euros for one MRSA patient hospital-day and 9,261.56 euros per MRSA case. The most expensive single measure was blocked beds in multibed rooms (305.75 euros/day), which accounted for 82% of the extra costs. Costs most likely were underestimated. CONCLUSIONS: Daily additional case costs amounted to 96% of social security payments. Blocked beds in multibed rooms accounted for more than 80% of these excess costs. Isolation has been scientifically validated and is required by law in Germany. Building an adequate number of single-bed rooms should help prevent spread and would greatly lower the added costs of infection.

Aged↗
PubMed2000

Post-intensive care unit pediatric hospital stay and estimated costs.

OBJECTIVE: For pediatric intensive care unit (ICU) survivors, to determine the proportion of hospital stay and estimated hospital costs accounted for by post-ICU care. DESIGN: Prospective study. SETTING: University teaching hospital. PATIENTS: Pediatric patients who survive an ICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Estimated relative daily costs were assumed as follows: ICU, with ventilator/ICU, not on ventilator/intermediate care unit/general pediatric hospital day, at 2:1:0.7:0.3, respectively. Estimated costs were expressed in arbitrary units as (number of days at each level of care) x (relative cost per day). The ICU phase was defined as the patient's first ICU admission only, and the post-ICU phase included intermediate care unit and general pediatric hospital days, as well as ICU readmission during the same hospitalization. Pre-ICU hospital activity was excluded from analysis. For 341 ICU survivors, post-ICU days (median, 4 days per patient) accounted for 62% of the total hospital stay. Post-ICU care accounted for one third of the total estimated hospital costs for ICU survivors. Patients with longer post-ICU stays could not be reliably identified at the time of ICU discharge according to their ICU length of stay, duration of mechanical ventilation in the ICU, age, ICU day 1 mortality probability, or diagnostic group (p>.05). CONCLUSIONS: Post-ICU care accounts for a substantial proportion of hospital stay and estimated costs for ICU survivors. These observations suggest that developing strategies to optimize hospital utilization at the time of ICU discharge may be important for controlling costs of recovery from critical illness.

Child, Hospitalized↗
PubMed1996

Pharmacoeconomics and formulary decision making.

Pharmacoeconomic assessment of formulary actions has become increasingly common in local, national, and international formulary decision making. Tactics for managing medication use include formulary management and drug policies. Pharmacoeconomic data can provide support for these formulary decisions. For example, pharmacoeconomic data can support the inclusion or exclusion of a drug on or from the formulary and support practice guidelines that promote the most cost-effective or appropriate utilisation of pharmaceutical products. Various strategies can be used to incorporate pharmacoeconomics into formulary decision making. These include using published pharmacoeconomic studies and economic modelling techniques, and conducting local pharmacoeconomic research. Criteria for evaluating the pharmacoeconomic literature, suggestions for employing economic models, and suggested guidelines for conducting pharmacoeconomic projects are discussed. Although most formularies are viewed as cost-containment tools, formularies should not be a list of the 'cheapest' alternatives. Today's formulary should contain agents that optimise therapeutic outcomes while controlling cost. Pharmacoeconomic assessments of formulary decisions help to ensure that the agents promoted by our formularies yield the highest outcome per dollar spent. A discussion of the process for formulary action in a US hospital, the influence of pharmacoeconomics on US formularies, and strategies for incorporating pharmacoeconomics into formulary decision making are presented in this paper.

Decision Making, Organizational↗
PubMed1994

Physician reimbursement in Medicare risk contracting.

The Medicare population remains largely unmanaged despite its increasing cost burden. With a few notable exceptions, health maintenance organizations (HMOs) have historically avoided serving this expensive segment. In many cases, the inability to control costs results from failing to understand the importance of specialist reimbursement mechanisms. This article examines the importance of these mechanisms and describes how to successfully capitate specialty physicians in a Medicare risk program. The article also includes a case study on a successful capitation agreement between an HMO and a specialty group.

Aged↗
PubMed1997

Solutions for adverse selection in behavioral health care.

Health plans have incentives to discourage high-cost enrollees (such as persons with mental illness) from joining. Public policy to counter incentives created by adverse selection is difficult when managed care controls cost through methods that are largely beyond the grasp of direct regulation. In this article, the authors evaluate three approaches to dealing with selection incentives: risk adjustment, the carving out of benefits, and cost- or risk-sharing between the payer and the plan. Adverse selection is a serious problem in the context of managed care. Risk adjustment is not likely to help much, but carving out the benefit and cost-sharing are promising directions for policy.

Economic Competition↗
PubMed1999

The role of respiratory care practitioners in a changing healthcare system: emerging areas of clinical practice.

OBJECTIVE: To evaluate shifts in respiratory care practice in the context of changing healthcare system and market dynamics. STUDY DESIGN: Telephone survey, structured interview, and case studies. METHODS: We conducted a telephone survey of 471 respiratory care practitioners (RCPs), drawn from the membership database of the American Association for Respiratory Care. We also interviewed 10 employers of RCPs and conducted 2 in-depth case studies to supplement our survey results. We used several statistical techniques to analyze our data, including calculation of population-weighted descriptive statistics and multivariate regression models. RESULTS: Changes in the healthcare system have prompted RCPs to broaden their practice settings, skills, and responsibilities. Respiratory care practitioners are taking part in managed care-related activities, such as cost control and disease management. We found that the need for certain skills and responsibilities varies by practice setting. In our interviews, employers considered RCPs cost effective providers for certain services. CONCLUSIONS: The practice of respiratory care is evolving to meet the changing needs of the healthcare system. A key challenge is to ensure appropriate growth and development of the respiratory care profession, as well as the delivery of appropriate services under new care management settings and processes.

Allied Health Personnel↗
PubMed1996

Judging hospitals by severity-adjusted mortality rates: the case of CABG surgery.

In many health care marketplaces, outcomes assessment is central to monitoring quality while controlling costs. Comparing outcomes across providers generally requires adjustment for patient severity. For mortality rates and other adverse outcomes comparisons, severity adjustment ideally aims to control for patient characteristics prior to the health care intervention. A variety of severity methodologies, specifically for hospitalized patients, are commercially available. Some have been adopted by state or regional initiatives for publicly comparing hospital outcomes. We applied 14 common severity measures to the same data set to determine whether judgments about risk-adjusted hospital death rates are sensitive to the specific severity method. We examined 7,765 patients undergoing coronary artery bypass graft (CABG) surgery at 38 hospitals. Unadjusted death rates ranged from 0% to 11.2% across hospitals. Comparisons of relative hospital performance were relatively insensitive to the severity adjustment method.

Adolescent↗
PubMed1984

A basic strategy for financing long term care.

As pressure mounts to contain Medicaid long term care spending, short-range "quick fixes" must be avoided. Three such false solutions in particular have shortcomings that may actually exacerbate long term care's financial dilemma because they are based on inadequate definitions of the problem. Two of these proposals--legislation to broaden family responsibility toward institutionalized elders on Medicaid and expanded state power to put liens on such elders' real property--err by trying to mandate "caring" and are predicated on a misunderstanding of the "spend-down" problem. The other proposal--to provide tax incentives to family members who care for elders--requires a large administrative apparatus, assumes an elasticity of supply that may not exist, and could disrupt the "gift relationship" on which family exchanges are often based. What is needed is a strategy with short term, intermediate, and long term objectives that move toward an insurance approach. The short term plan should lay the groundwork for intermediate strategy and control costs by changing rate-setting methods and putting limits on facility construction. The intermediate plan should change the problem's definition from one of merely controlling Medicaid long term care expenditures to one of efficiently managing state resources for the elderly through the development of state financing and local delivery systems that target older persons in greatest need. An effective means of doing this is through the creation of social/HMOs, which have five key features: integration of service responsibility and authority; flexibility in organizational design; balanced clientele; pooled prepaid funding; and financial risk for the provider organization. Finally, the long term strategy should transfer much of the long term care financial burden from individuals and state Medicaid agencies to insurance mechanisms. Many individuals would thus avoid impoverishment caused by health care spending and Medicaid would greatly reduce its caseload. Insurance coverage is an appropriate funding mechanism, moreover, in that relatively few persons will ever incur high costs.

Aged↗
PubMed1998

Cost-effectiveness of SSRIs: a European perspective.

BACKGROUND: Evaluating treatments for depression is of great importance given that estimates of lifetime prevalence range up to 20 per cent. The class of antidepressants known as Selective Serotonin Reuptake Inhibitors (SSRIs) has been a major innovation in this area, but has also raised questions about their cost-effectiveness as a first-line treatment, due to their high price compared to other drugs. AIMS OF THE STUDY: The study aimed to contribute to this debate, from within the context of European health care systems. These systems share a common set of pressures to contain costs, many of which, in Europe, are funded from public finances, unlike the US system, with its greater private sector involvement. METHODS: A range of published papers were reviewed. They all covered the general area of costs and SSRIs and were evaluated in a European context. RESULTS: Some studies have considered the possible use of SSRIs purely as a matter of accounting costs. Not surprisingly, they have argued against switching, on the grounds of high acquisition costs. However, studies based alongside clinical trials have incorporated efficacy into the analysis. They have produced cost-effectiveness or cost utility based arguments in favour of the SSRIs or other innovative, high-price antidepressants. Another approach has used retrospective analysis of real patients'experience of treatment. This has shown that, if the full costs of treatment are considered, there is an argument for switching from Tricyclic Antidepressants (TCAs) to first-line use of SSRIs. Most economic evaluations have used decision analysis techniques and thus are subject to all the qualifications that apply to such modelling exercises. With only one exception, all the studies in this category were in favour of switching to newer antidepressants. While efficacy was generally accepted as roughly equal, the newer products were seen as less toxic and better tolerated. The consequence was savings in health care costs that outweighed the increase in drug acquisition costs. DISCUSSION: The economic evaluation papers in this review have almost all challenged the view that health care providers should regard SSRIs as 'too expensive' for widespread use. Instead, if one integrates clinical outcomes with a full range of health care costs the high-price products may be more cost-effective. Certainly that is the message from this review, although the observations must be qualified, as most of the studies considered were UK based. CONCLUSIONS: In all health care systems there are now incentives to control costs, which may act as a disincentive to the use of SSRIs, but if those responsible for drug budgets also have financial responsibilities outside the drug budget they will also have an incentive to control those areas. In this case, there is a body of evidence to suggest they would gain by switching to SSRIs. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Decisions on favoured classes of antidepressant for first-line treatment should not be made purely on the basis of drug costs. The implications for all aspects of health spending should be included in the deliberations. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The impact of spending across all budgets should be considered when drawing up policy on the use of new health care technologies, such as the SSRIs. IMPLICATIONS FOR FURTHER RESEARCH: Most studies in this area have used modelling techniques, which are subject to a number of limitations. They have also used results taken from the artificial environment of clinical trials. Future research should aim to generate economic evaluations based on effectiveness amongst real patients in clinical practice.

Journal Article↗
PubMed2000

Cost-effective management of benign positional vertigo using canalith repositioning.

OBJECTIVE: The misdiagnosis and inappropriate treatment of benign positional vertigo have resulted in significant costs to the medical system. In the current medical-economic climate, there is an increased emphasis on cost control. Recent studies have shown that the canalith repositioning procedure (CRP) is effective; the next step is to show the impact of CRP in cost-effective management of benign positional vertigo. METHODS: Forty-six of 100 patients who underwent CRP for benign positional vertigo responded to a survey regarding the financial impact of their disease. They were asked to subjectively estimate the sum of all disease-related expenses. Objective substantiation of this number was estimated by tabulating physician data, laboratory data, and failed treatment costs. RESULTS: The subjective figure totaled $2684.74 per individual. Summation of the tangible objective figures yielded $2009.63 per patient, corroborating the subjective figure. CONCLUSIONS: Because CRP is a relatively simple procedure that can obviate many wasted expenses in most patients, we believe that it is very cost-effective and should be incorporated into routine practice.

Cost of Illness↗
PubMed2004

Analysis of occupational exposures associated with emergency department thoracotomy.

BACKGROUND: Although previous studies have examined the cost effectiveness of emergency department thoracotomy (EDT), provider risk has not been included in these analyses. This study examined the costs associated with provider exposure to human immunodeficiency virus (HIV) and hepatitis from percutaneous injury during EDT. METHODS: A decision tree describing the occupational risks and costs associated with EDT was created. Exposed providers undergo initial counseling, evaluation, and HIV postexposure prophylaxis and treatment as recommended by the Centers for Disease Control. Costs are reported from a health care system perspective in year-2000 dollars. The following prevalences were assumed: HIV (7.1%), hepatitis C (18%), and provider percutaneous injury rate (10%). Sensitivity analyses were performed by varying the prevalence of disease and the probability of seroconversion. RESULTS: According to the authors' model assumptions, the probability is 0.00004 for HIV and 0.0027 for chronic hepatitis C seroconversion. The total additional cost per thoracotomy associated with an exposure is dollars 1,377. CONCLUSIONS: Emergency department thoracotomy is associated with important provider medical risks. Future analyses of EDT should include these factors in reports on the value of this procedure.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Patterns of health care costs associated with depression and substance abuse in a national sample.

OBJECTIVE: The associations between self-reported depressive and substance use disorders and estimated health care costs were examined in a representative national sample. METHODS: Data were from the 1994 National Health Interview Survey (N=77,183). Respondents who reported depressive symptoms or major depression (depressive syndromes) or a substance abuse disorder in the past year were compared with respondents who did not report these conditions. The mean number of inpatient days and outpatient visits in both the general medical and the specialty mental health settings were determined, and costs per individual were calculated based on mean costs of such care in each respondent's geographic region. Multivariate models were constructed to calculate mean costs, controlling for demographic variables, insurance coverage, and physical health status. RESULTS: Individuals with self-reported depressive syndromes or substance abuse had mean health care costs that were $1,766 higher than costs for individuals without these conditions. Depressive syndromes were associated with increases in both inpatient and outpatient costs. However, substance abuse was almost exclusively associated with increased inpatient expenditures rather than outpatient costs. The magnitude of increased costs associated with mental disorders was substantially larger for patients in fee-for-service plans than for those in health maintenance organizations. Only 14.3 percent of visits made by individuals reporting depressive syndromes or substance abuse were made to specialty health providers (psychiatrists, psychologists, and social workers). CONCLUSIONS: Health care costs of people with self-reported mental illness varied significantly across diagnoses and systems of care. It is crucial that researchers estimating increased costs associated with mental illness account for both diagnostic and system factors that can influence the estimates.

Adult↗
PubMed1994

Managing provider networks through expert systems: use of patterns of treatment to address overutilization.

Among the most important contributors to rising health care costs is excess utilization of services. Sophisticated clinical criteria, encoded as an expert system in software, allow identification of probable excess utilization in large claims data sets. These systems can be used to adjudicate claims, resulting in direct cost savings, or to profile physicians and other providers, facilitating creation and maintenance of networks. These systems are used by traditional payers to promote quality, control costs, and enhance competitiveness and are beginning to be used by nontraditional payers, such as physician groups and hospital-based networks.

Ambulatory Care↗
PubMed1984

Providers face business of growing private UR.

In response to continuing increases in health care costs, big business has begun to lower the boom on hospitals and physicians through outside utilization review. Physicians, however, are seen as the key to controlling costs.

Commerce↗
PubMed1991

[Private accident insurance in Switzerland with reference to liability insurance as a part of social security].

On the Swiss market there exist various different accident insurance schemes and systems. Private accident insurance which is offered by the private insurers, date back to the middle of the 19th century. Since 1912 accident insurance is compulsory for all employees working in particularly dangerous industries, since 1984 it covers all employees in the country. In Switzerland there exists no general compulsory accident insurance. To perform as insurance carriers are qualified: private insurance companies, the Swiss Accident Insurance Company, and a number of the social health (sickness) insurers. Depending on the insurance system there are different approaches to renumerate the health costs. In the various social insurance systems the patient is rather free to chose his doctor and hospital (among those who have a contract with the insurer); in private insurance he is completely free. Yet the billing systems and the applicable rates and tarifs differ considerably. There are trends to simplify these systems and bring them more into mutual accordance. Due to the important rise of the health costs in Switzerland, there exists the danger that possible simplifications will bring about more public influence yet less private initiative and less incentives to really control costs without lessening the patients' possibilities.

Humans↗