Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.
OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement. (+info)
Mental health/medical care cost offsets: opportunities for managed care.
Health services researchers have long observed that outpatient mental health treatment sometimes leads to a reduction in unnecessary or excessive general medical care expenditures. Such reductions, or cost offsets, have been found following mental health treatment of distressed elderly medical inpatients, some patients as they develop major medical illnesses, primary care outpatients with multiple unexplained somatic complaints, and nonelderly adults with alcoholism. In this paper we argue that managed care has an opportunity to capture these medical care cost savings by training utilization managers to make mental health services more accessible to patients whose excessive use of medical care is related to psychological factors. For financial reasons, such policies are most likely to develop within health care plans that integrate the financing and management of mental health and medical/surgical benefits. (+info)
Feasibility of direct discharge from the coronary/intermediate care unit after acute myocardial infarction.
OBJECTIVES: This investigation was designed to determine the feasibility and cost-effectiveness of direct discharge from the coronary/intermediate care unit (CICU) in 497 consecutive patients with an acute myocardial infarction (AMI). BACKGROUND: Although patients with an AMI are traditionally treated in the CICU followed by a period on the medical ward, the latter phase can likely be incorporated within the CICU. METHODS: All patients were considered for direct discharge from the CICU with appropriate patient education. The 6-week postdischarge course was evaluated using a structured questionnaire by a telephone interview. RESULTS: There were 497 patients (men = 353; women = 144; age 63.5 +/- 0.6 years) in the study, with 29 in-hospital deaths and a further 11 deaths occurring within 6 weeks of discharge. The mode length of CICU stay was 4.0 days (mean 5.1 +/- 0.2 days): 1 to 2 (12%), 3 (19%), 4 (21%), 5 (14%), 6 to 7 (19%) and > or = 7 (15%) days, respectively with 87.2% discharged home directly. Of the 425 patients surveyed, 119 (28.0%) indicated that they had made unscheduled return visits (URV) to a hospital or physician's office: 10.6% to an emergency room, 9.4% to a physician's office and 8.0% readmitted to a hospital. Of these URV, only 14.3% occurred within 48 h of discharge. Compared to historical controls, the present management strategy resulted in a cost savings of Cdn. $4,044.01 per patient. CONCLUSIONS: Direct discharge from CICU is a feasible and safe strategy for the majority of patients that results in considerable savings. (+info)
Potential savings from generic prescribing and generic substitution in South Africa.
Generic prescribing and generic substitution are mechanisms for reducing the cost of drugs. The purpose of this study was to assess the extent to which generic prescribing by private medical practitioners and generic substitution by private pharmacists is practised in South Africa and to estimate the potential savings from these two practices. Prescriptions from 10 pharmacists were collected on four randomly selected days. Computer printouts of all the prescriptions dispensed on these four days together with the original doctor's prescription were priced using a commercially available pharmacy dispensing computer package. A total of 1570 prescriptions with a total number of 4086 items were reviewed. Of the total prescriptions, 45.7% had at least one item for which there was a generic equivalent. Of the 961 drugs which had generic equivalents, 202 (21 %) were prescribed using the generic name of the drug. Only 0.3% of prescribers prohibited generic substitution. The cost of the prescription as dispensed was 1.4% (mean cost: R116.19 vs R117.84) below that of the original doctor's prescriptions, indicating the marginal benefit from the current low substitution rate of 13.9% by pharmacists. About 6.8% of the cost of the original doctor's prescriptions (mean cost: R117.84) could have been saved if total generic substitution (mean cost: R109.65) was practised. The cost of the prescriptions with only brand name items (mean cost: R120.49) would have been 9.9% higher than if generic drugs were used. Current restrictive prescribing and dispensing practices result in marginal cost savings from generic prescribing and generic substitution. Both these practices have a potential to reduce drug costs, if actively encouraged and practised to maximum capacity. It is noteworthy, however, that the potential savings from generic prescribing and substitution are at most 9.9% in the absence of any changes in types of drugs prescribed. (+info)
Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital.
OBJECTIVE: To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics. DESIGN: Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis. SETTING: Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams. MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF. CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change. (+info)
Outcomes for control patients referred to a pediatric asthma outreach program: an example of the Hawthorne effect.
A study was designed to determine whether identification of high risk for exacerbations of asthma based on pediatrician concern, emergency department visits, or hospital stays results in a decrease of resource utilization because of referral to an asthma outreach program even if the intervention does not take place. The findings for such a group were compared with those for a group who did undergo intervention with an asthma outreach program. Fifty-six patients 1 to 14 years of age were assigned to one of two groups. The control group (those who did not undergo intervention) had consistent but not statistically significant reductions in utilization of emergency visits, hospitalizations, and dollars spent (21%, 24%, and 32%, respectively). The group who underwent intervention with the asthma outreach program had large and statistically significant decreases in the same parameters (emergency visits, 60%, P = 0.001; hospital stays, 74%, P = 0.008; dollars spent, 72%, P = 0.004). However, the apparently insignificant effect of the reductions in utilization by the control group substantially altered interpretation of the outcomes of the study. Cost savings were reduced from $11.69 per dollar spent on intervention to $6.49 per dollar spent. In before-and-after studies such as those typically conducted during continuous quality improvement projects, which typically do not have control groups, investigators need to consider control group effects when they assess the results of intervention. (+info)
A program to reduce discharge delays in a neonatal intensive care unit.
Our hypothesis was that a program designed to identify the causes of discharge delays would reduce the length of stay in our neonatal intensive care unit. We reviewed every admission from January, 1994, to December, 1995. A discharge delay was defined as any delay not related to illness after the infant was cleared for release. Discharge delays were divided into the following categories: primary healthcare team, organizational, discharge planning, family, monitor related, and other. Potential discharge delays were identified daily according to established criteria. Actual discharge delays were reviewed monthly at a staff meeting attended by representatives of a multidisciplinary team. We identified 116 discharge delays, which accounted for 480 patient days. Eighty-three discharge delays accounted for 302 patient days in 1994, and 33 discharge delays for 178 patient days in 1995. Discharge delays ranged from 1 to 34 days, with an average of 4.1 days added per patient. Infants with discharge delays had a case mix index of 9.32. The average case mix index for the neonatal intensive care unit was 6.25 during 1994 and 5.18 during 1995, an average of 5.71 for the review period. Forty-four percent of infants who had discharge delays had private insurance, 55% had Medicaid, and 1% had self-payment arrangements. Eighty-eight of 116 discharge delays were caused by circumstances beyond the control of the primary care team. An additional 25 of 116 discharge delays were the result of our policy requiring 48 hours free of apnea-bradycardia alarms before discharge. Discharge delays for 1994 cost $226,298 ($749/day). For 1995, discharge delays cost $41,553 ($233/day) for a total cost of $262,431. Total savings in 1995 versus 1994 was $184,745 ($516/day). Despite the low birth weight and relatively severe illnesses of the infants, we believe that a focused team approach and monitoring for potential discharge delays can result in considerable reduction in hospital stay and cost. (+info)
Cost recovery in Ghana: are there any changes in health care seeking behaviour?
The study aimed to investigate the impact on health care seeking behaviour of the cost-sharing policies introduced in Ghana between 1985 and 1992. Qualitative research techniques were used to investigate the behaviour of patients after the introduction of these policies. Focus group discussions of cohorts of the population and in-depth interviews of health workers and selected opinion leaders were used to collect data from rural and urban health care facilities in three districts of Ghana. The study findings indicate that the cost recovery policies have led to an increase in self-medication and other behaviours aimed at cost-saving. At the same time, there is a perception of an improvement in the drug supply situation and general health delivery in government facilities. The study advocated enhanced training of drug peddlers and attendants at drug stores, especially in rural areas. User fee exemption criteria need to be worked out properly and implemented so that the very needy are not precluded from seeking health care at hospitals and clinics. (+info)