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PubMed2003

Agreement between insurance claim and self-reported hospital and emergency room utilization data among persons with diabetes.

As part of a retrospective evaluation of a diabetes management program, the agreement between self-reported and insurance claim data on hospitalization and emergency room utilization was examined. Data agreement on hospitalization or emergency room visits between the two collection modes was evaluated through the use of simple agreement proportions and the kappa agreement statistic. A total of 1,230 participant responses were studied. The proportions of patients with hospitalization or emergency room visits were indistinguishable between the self-reported and medical claims data, and kappa statistics also indicated good-to-excellent agreement between data sets. The percentages of participants whose self-reported hospitalization and emergency room utilization exactly matched data derived from insurance claims were high (89.1% and 87.2%, respectively). Furthermore, the kappa statistics of agreement for the number of hospitalizations (0.6366) and emergency room visits (0.5390) indicate good agreement between self-reported and insurance claim data. The results of this study suggest either self-reported or insurance claims data can be used to evaluate the impact of health care interventions on hospital or emergency room utilization.

Aged↗
PubMed1990

Acute hospital costs of pediatric trauma in the United States: how much and who pays?

National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sex-specific estimates of the numbers of hospital admissions and expenditures are reported for subgroup of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 266,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4,5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidental Falls↗
PubMed1999

Death by managed care--denial of hospitalization for headache.

A 47-year-old man with a severe headache disorder, taking meperidine injections 8 to 12 times a day and approximately 6 butalbital-containing tablets per day, was denied hospitalization for the management of headache and died while awaiting evaluation for detoxification by a psychiatric facility. The criteria for hospitalization and the implications of the denial of care by insurance companies are explored. The biases against the publication of such cases are reviewed.

Headache↗
PubMed2002

Stupid payment tricks.

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Blue Cross Blue Shield Insurance Plans↗
PubMed2002

Patient compliance with managed care emergency department referral: an orthopaedic view.

OBJECTIVE: Patient compliance with emergency department (ED)-generated referral is an important part of the delivery of quality health care. Although many studies from non-managed care health centers have reported on ED patient compliance, no studies have reported on this in a managed care setting. The objective of this study is to examine patient compliance with ED-generated referral and to produce a benchmark of follow-up rates possible in a capitated managed care system. That is to say, in a health care system whose members pay a uniform per capita payment or fee, one that has salaried physicians, owns its own hospitals, and has a mechanism of transition from ED to outpatient clinic that ensures referral accessibility. DESIGN: Retrospective review of consecutive ED patient compliance with ED-generated referral. PATIENTS/METHODS: All consecutive patients who presented to a managed care hospital's ED with an acute fracture and who were given an outpatient referral during the period from 23rd December 1998 to 23rd January, 1999. Of 8000 consecutive ED patients, 234 were included in the study. Compliance with ED-generated referral was determined from outpatient clinic records. RESULTS: Of the 234 patients treated in the ED and referred, 222 (94.9%) complied with follow-up appointments. CONCLUSIONS: We have demonstrated that an ED patient follow-up compliance rate of 94.9% can be obtained. It is probable that the high compliance rate is due to the features of the system studied. The high rate may also be related to the specific diagnosis studied, although previous literature reports poor ED patient compliance for the same diagnosis in a different ED setting. Additional research is needed to determine whether the high compliance rate reported in this study can be obtained in ED settings that are not part of a similar managed care system and to determine the role of referral accessibility (or inaccessibility) in current ED settings.

Adult↗
PubMed1992

Special report on liability and insurance. An update on assignment of patient benefits under ERISA.

While the holdings in Davidowitz and Arkansas Blue Cross & Blue Shield arose in different contexts, they both reflect the courts' increasing willingness to consider the importance of cost containment in the health insurance arena, even though patient accessibility to health care may be restricted as a result. If the holding in Davidowitz is not successfully appealed, providers may need legislative relief in order to retain their ability to take valid assignments of patient claims for payment from ERISA plans. It is uncertain whether such legislation can be sought at the state level or must instead come from Congress due to ERISA preemption of state legislation. Clearly, the district court decision on remand in Arkansas Blue Cross & Blue Shield will be closely watched for any light it may shed on this question. On a pragmatic note, providers who have not entered into "participation" agreements with insurers or other private payors may now have a greater incentive to do so, and "nonparticipating" providers who continue to obtain assignments from patients in order to collect directly from insurers or other private payors should determine on a case-by-case basis whether the source of the patient's benefits is a group health plan--which is likely to fall under ERISA and may contain nonassignment provisions--or some other form of coverage. For an additional perspective on insurers' responses to copayment waivers, see Newsletter, Vol. 6, No. 10, October 1991, at 7.

Arkansas↗
PubMed1993

Hospital pricing: cost shifting and competition.

The issue of cost shifting has taken on enormous policy implications. It is estimated that unsponsored and undercompensated hospital costs--one measure of cost shifting--has totaled $21.5 billion in 1991. The health services research literature indicates that hospitals set different prices for different payers. However, the empirical evidence on hospitals' ability to raise prices to one payer to make up for unsponsored care or lower payments by other payers is mixed at best. No study has concluded that hospitals have raised prices to fully adjust for such actions. The extent of cost shifting is limited by the market. When a hospital has market power, it is able to set prices above marginal costs. However, when a buyer has enough patient/subscribers and a willingness to direct them to particular providers based on price considerations, hospitals have less flexibility in raising prices above costs. Thus, the extent of cost shifting is limited by the market. Cost shifting is not as easy as it may have been in the past because the nature of hospital and insurer competition has changed radically in the last decade. While hospital quality, services, and amenities still matter, some buyers are increasingly concerned about the price they pay. Evidence from studies of PPO and HMO negotiations with hospitals suggests that hospitals' market power is eroding, at least in some areas. In areas with relatively few hospital competitors and little PPO or HMO activity, Medicaid and Medicare price reductions and uncompensated care burdens will be partially absorbed by higher prices paid by private payers. In more price sensitive markets and in markets in which prices to private payers have risen to those commensurate with the market power of local hospitals, such cost shifting will not occur. A market-based approach in hospital pricing requires an explicit policy for the uninsured. In a competitive market, a hospital that traditionally cared for the uninsured by spending some of its profits on them will be unable to do so, at least to the same extent as it did in the past. Increased competition in health care without consideration of the uninsured will decrease the uninsured's access to care.

Contract Services↗
PubMedDate not supplied

The crunch cometh.

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Canada↗