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Results for “Reimbursement Mechanisms”

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At least 19 recordsLinked to original sources
PubMed1995

Acceptability to general practitioners of national health insurance and capitation as a reimbursement mechanism.

OBJECTIVE: To determine general practitioners' attitudes to national health insurance (NHI) and to capitation as a mechanism of reimbursement. To explore determinants of these attitudes. DESIGN: Cross-sectional survey by means of telephone interviews; four focus group discussions. SETTING: Cape Peninsula. PARTICIPANTS: 174 GPs randomly sampled from a total population of 874. MAIN OUTCOME MEASURES: Acceptance of NHI, acceptance of capitation. MAIN RESULTS: 63.3% approved of NHI. More than 81% approved of NHI if GPs would be able to maintain their independent status, e.g. own premises and working hours; 82.3% said NHI would be a more equitable system of health care, 88% approved of the fact that NHI would make care by GPs more accessible, and 73% said they would have the capacity to treat more patients. However, 61.3% of GPs disapproved of capitation as a form of reimbursement. CONCLUSIONS: Most GPs in the Cape Peninsula were amenable to some form of NHI. However, the proportion of GPs who approved the introduction of NHI varied depending on details of the NHI system such as payment mechanisms, workload, income and effects on professional autonomy. A national survey of medical practitioners is recommended. The implications of GPs' preferences concerning the reimbursement mechanism for the feasibility of implementing a NHI system in South Africa require serious consideration by policy-makers.

Adult↗
PubMed2002

Reimbursement mechanisms for glycoprotein IIb/IIIa-receptor inhibitors.

Changes in health care reimbursement policies as they apply to glycoprotein (GP) IIb/IIIa-receptor inhibitors are discussed. GP IIb/IIIa-receptor inhibitors significantly reduce the frequency of myocardial infarction and death in patients with non-ST-segment-elevation (NSTE) acute coronary syndromes (ACSs) and in those undergoing percutaneous coronary intervention (PCI). GP IIb/IIIa-receptor inhibitors are increasingly being used in ambulatory settings, such as the emergency department and the cardiac catheterization laboratory. Recent public policy decisions now provide appropriate reimbursement mechanisms for the outpatient use of GP IIb/IIIa-receptor inhibitors. As a result, small community hospitals and large tertiary care centers can both be appropriately reimbursed for these agents. In August 2000, the Center for Medicare and Medicaid Services developed the Ambulatory Payment Classification system. This system provides compensation for GP IIb/IIIa-receptor inhibitor acquisition and administration and is of special benefit to community hospitals. In addition, recent revisions to the inpatient prospective reimbursement (Diagnosis-Related Group) system increased payment for the use of an early aggressive (invasive) strategy in these patients. Together, these reimbursement mechanisms facilitate the early use of GP IIb/IIIa-receptor inhibitors in patients with NSTE ACSs and in those undergoing PCI. Recent policy changes facilitate reimbursement of hospitals for the use of GP IIb/IIIa-receptor inhibitors.

Angioplasty, Balloon, Coronary↗
PubMed2000

Coding and reimbursement mechanisms for physician services in hospice and palliative care.

Many physicians misperceive that the current coding system used to bill third-party payers in the United States does not include codes related to hospice and palliative care. This article will help physicians and hospice and palliative care providers to: 1) understand how to code for physician services related to hospice and palliative care; 2) review the documentation required to support such services; 3) understand the differences between the reimbursement mechanisms to be used when the patient is enrolled in the Medicare Hospice Benefit, and the usual reimbursement mechanisms; and 4) understand some of the approaches for funding non-physician palliative care services for patients not enrolled in the Medicare Hospice Benefit.

Journal Article↗
PubMed1983

Federal low vision services reimbursement mechanisms.

This paper is a synopsis of the present federal legislative programs that offer reimbursement for low vision services. The programs are reviewed with specific attention given to 1) The Social Security Act, 2) the Education of the Handicapped Act, 3) the Rehabilitation Act, and 4) the Veteran's and Uniformed Services Act. A comparison of these programs is presented along with a brief discussion about the effectiveness of these programs to meet our present and future needs.

Adolescent↗
PubMed1983

A capitation-based prospective reimbursement mechanism for linking academic medical centers with health maintenance organizations.

Recent changes in the medical marketplace have led to increased competition among health care delivery organizations. Despite this, the academic medical center (AMC) and the health maintenance organization (HMO), even with apparently divergent goals, can interact so that both parties benefit. By developing a risk-sharing prospective reimbursement contract, the HMO can better predict tertiary care expenses. Concomitantly, the AMC can broaden its market and increase its access to patients requiring its technologically sophisticated services. This article presents a mechanism for creating a prospective reimbursement contract with mutually beneficial incentives. Implications of the methodology are also discussed.

Academic Medical Centers↗
PubMed1982

Insurance reimbursement mechanisms for rehabilitation equipment and environmental modifications.

Third party payment mechanisms are reviewed from the viewpoint of one commercial insurer. Attention is focused upon insurance coverage for rehabilitation equipment, environmental modifications, orthotics, prosthetics, and durable medical equipment. Numerous variables influence coverage decisions. Typical examples, unique in rehabilitation literature, illustrate situations related to the major types of insurance (Group Health, Miscellaneous Lines, Workers' Compensation, and Reinsurance). The importance of the rights of disabled persons and the impact of national financial estimates are discussed. Consideration is given to several approaches which might improve the benefits available. Techniques to cope with the system include prompt communication, accurate correspondence, and employer policyholder awareness.

Health Maintenance Organizations↗
PubMedDate not supplied

Community resources for clients with mobility problems.

Clients are leaving the hospital "quicker and sicker," and they frequently have acute care needs that must be met by resources outside the hospital setting. Community resources are diverse, vary widely from place to place, and have no central administration. Thus, using them can be challenging for both the nurse, client, and family. Reimbursement mechanisms underlie a person's ability to use resources and receive health care. By presenting two actual case scenarios where clients have mobility problems commonly seen by orthopaedic nurses, the authors discuss the community resources available, avenues of access to them, and their reimbursement mechanisms.

Activities of Daily Living↗
PubMedDate not supplied

The resource utilization groups system of nursing home reimbursement policies: influences on occupational therapy practice.

OBJECTIVE: This study explored the effects of federal and state reimbursement mechanisms on occupational therapy practice in the nursing home setting, specifically, the selection and scheduling of patients for treatment programs, the content of the therapy provided, and the documentation requirements. METHOD: A questionnaire developed for the study was mailed to the chief occupational therapist in each of the 171 nursing homes located in New York city. Descriptive data on the research variables were collected from 83 respondents. RESULTS: Government regulation and reimbursement mechanisms specifically affected therapists' treatment decisions and patient programming and scheduling in the nursing home setting. Survey results described the clinical impact of the resource utilization groups (RUGs) data collection periods. Negative effects were seen in a substantial incidence of withholding therapies from patients and the decline in the use of some traditional occupational therapy treatments. Positive effects included an increase in staff and equipment and therapists' improved documentation skills. CONCLUSION: Occupational therapy practitioners in the nursing home setting need to find ways to live with the realities of government reimbursement without compromising professionalism or clinical judgment. Documentation is the key to assuring that patients receive the therapy they need. Therapists should be aware of the regulations, document accordingly, and review those cases that were denied reimbursement to learn of documentation errors.

Health Policy↗
PubMed1995

The effect of managed care on the treatment outcome of substance use disorders.

This study examined the effect of managed care and other reimbursement mechanisms on the outcome of substance abuse treatment at a single treatment facility. A retrospective review of 1594 patient records yielded treatment utilization, diagnostic, and demographic data. Recidivism rates for intensive managed care, traditional managed care, private pay, and state-funded groups of patients were compared. Results showed that, contrary to expectations, recidivism rates were not different for managed vs nonmanaged care patients. In addition, recidivist patients had significantly more ICD-9 diagnoses than nonrecidivist patients. A discussion of future research suggests that other outcome measures need to be examined in addition to recidivism rate, such as psychosocial functioning following treatment and indicator(s) of severity of illness, to better determine the effect of managed care and other reimbursement mechanisms on treatment outcome.

Adult↗
PubMed2001

Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms.

PURPOSE: Percutaneous radiofrequency (RF) ablation is a promising technique for the treatment of hepatic malignancies. However, its cost-effectiveness has not been established. The purpose of this study is to determine the cost-effectiveness of RF ablation compared to palliative care in the treatment of hepatocellular cancer and colorectal liver metastases. This study also seeks to evaluate the effects of transition from traditional to newly implemented prospective outpatient reimbursement mechanisms on RF ablation cost-effectiveness. MATERIALS AND METHODS: The marginal direct costs of a percutaneous RF ablation treatment strategy were compared to palliative care over a range of survival benefits with use of a cost-effectiveness model built from the perspective of the payer. Variables used in the model, including complication rates and procedure efficacy, were obtained from the literature and the authors' experience with 46 consecutive patients. RESULTS: The cost-effectiveness of a standardized percutaneous RF ablation treatment strategy compared to palliative care was $20,424, $11,407, $5,034, and $3,492, respectively, per life-year (LY) gained when marginal median survival conferred by RF ablation is 6 months, 1 year, 3 years, and 5 years. The RF ablation treatment strategy would be required to generate 6.14, 2.26, and 1.10 months of marginal median survival benefit to achieve strict ($20,000/LY gained), moderate ($50,000/LY gained), and generous ($100,000/LY gained) cost-effectiveness thresholds. Cost-effectiveness was sensitive to the number of lifetime treatments, hours of observation time, frequency of follow-up evaluations, cost of abdominal computed tomography, and decision to perform RF ablation as an inpatient or outpatient. CONCLUSION: Percutaneous RF ablation is a cost-effective treatment strategy compared to palliative care and has likely already achieved the survival benefit required to meet even a strict cost-effectiveness criterion. Dependence on reimbursement mechanism highlights the importance of concordance between policy and RF ablation technology. The results of this study allow flexible application of cost-effectiveness data despite current uncertainties in treatment and survival data and heterogeneity in treatment populations.

Catheter Ablation↗
PubMed1992

Physician responses to fee-for-service and capitation payment.

The ability to achieve reductions in health care costs is determined in part by physician payment mechanisms. This study observes the response to a change in the reimbursement mechanism by a group of physicians who participated in a fee-for-service plan and then formed an IPA using capitation payment for primary care physicians and a reduced fee schedule for specialists. Patient benefits were similar under the two plans. Analyses of data for a group of continuous enrollees show that the change in the physician payment mechanism was associated with a reduction in hospitalizations but increases in length of hospital stay and number of ambulatory visits. These increases may have occurred because capitation for primary care physicians and a reduced fee schedule for specialists led to a greater number of referrals with no incentive in place for reductions in length of stay for specialty admissions.

Ambulatory Care↗
PubMed1995

Weaving reimbursement of surgical dressings into the plan of treatment.

Caring for chronic wounds in today's rapidly changing healthcare environment can present a variety of challenges to the nurse. The risk of these challenges being transformed into obstacles is exacerbated by a lack of knowledge of the reimbursement mechanisms for the dressings needed for wound management. A clear and current understanding of reimbursement should be integrated into the plan of treatment. This article attempts to clarify present Medicare policy for coverage and reimbursement of dressings utilized for chronic wound care.

Bandages↗
PubMed2002

Hospital outpatient prospective payment under Medicare: understanding the system and its implications.

The newly implemented Medicare hospital outpatient prospective payment system provides fixed prospectively determined reimbursement for technical and other nonphysician services provided to beneficiaries in the hospital outpatient setting. As such, it represents the latest attempt by the federal government to control health care costs through prospective bundled payment systems such as the well-known Medicare diagnosis-related group system for hospital inpatients. The new system is complex, however, with several discrete reimbursement mechanisms possible for the same service. This complexity, in concert with the major change in outpatient reimbursement that the system represents, creates considerable uncertainty for radiologists and for medicine in general. It is incumbent on the radiology community to understand and assess the hospital outpatient prospective payment system and to work with the Centers for Medicare and Medicaid Services to minimize any potential negative effects on the profession and on patients.

Ambulatory Care↗