Patterns of anti-inflammatory therapy in the post-guidelines era: a retrospective claims analysis of managed care members.
Published and widely disseminated guidelines for the care and management of asthma characterize asthma as a chronic, inflammatory disease and propose specific recommendations for therapy with inhaled anti-inflammatory medications. In a retrospective analysis of medical and pharmacy claims data of approximately 28,000 asthmatic members from five managed care settings, the dominant pattern of pharmacologic therapy that emerged was the use of bronchodilators without inhaled anti-inflammatory drug therapy. In addition, a significant proportion of asthmatic patients received no prescription drug therapy for asthma. Less than one third of asthmatic patients received any anti-inflammatory therapy and the majority of these received one or two prescriptions per year. Specialist physicians were two to three times more likely than non-specialists during a study period of 1 year to prescribe an anti-inflammatory medication, and were half as likely to have their asthmatic patients experience an emergency department or hospital event. This database analysis suggests that greater conformity with guidelines and/or access to specialist physician care for asthmatic members will lead to improved patient outcomes. (+info)
Implications of managed care denials for pediatric inpatient care.
With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed. (+info)
Course of antidepressant treatment with tricyclic versus selective serotonin reuptake inhibitor agents: a comparison in managed care and fee-for-service environments.
We compared course of treatment with tricyclic antidepressant drugs (TCADs) and selective serotonin reuptake inhibitors (SSRIs) to assess interactive effects of antidepressant type with payer type and patient characteristics. A nationwide sampling of adults (n = 4,252) from approximately equal numbers of health maintenance organization (HMO) and indemnity enrollees were prescribed no antidepressants for 9 months, and thereafter prescribed a TCAD or SSRI. Using a retrospective analysis of prescription claims, these cohorts of TCAD and SSRI utilizers were followed for 13 to 16 months after their initial antidepressant prescription. Outcome measures included (1) termination of antidepressant treatment before 1 month; and (2) failure to receive at least one therapeutic dose during treatment lasting 3 months or more. Rates of premature termination and subtherapeutic dosing were significantly higher for TCAD-treated than SSRI-treated patients, and for HMO than indemnity enrollees. The interaction of HMO enrollment and TCAD use was associated with particularly high rates. Excluding patients terminating in the first month, the proportions of TCAD and SSRI utilizers remaining in treatment over time were not significantly different. We conclude that SSRIs may provide advantages in treatment adherence and therapeutic dosing, particularly in environments with limited prescriber time. The first month of treatment may be especially critical in determining compliance. (+info)
Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons.
We examined charge data for health insurance claims paid in 1992 for persons under age 65 covered by a large California managed care plan. Charge and utilization comparisons between podiatrists and orthopedic surgeons were made for all foot care and for two specific foot problems, acquired toe deformities and bunions. Podiatrists provided over 59% of foot care services for this commercial population of 576,000 people. Podiatrists charged 12% less per individual service than orthopedists. However, podiatrists performed substantially more procedures per episode of care and treated patients for longer time periods, resulting in 43% higher total charges per episode. Hospitalization was infrequent for all providers, although podiatrists had the lowest rates. In a managed care setting in which all providers must adhere to a preestablished fee schedule, regardless of specialty, the higher utilization by podiatrists should lead to higher overall costs. In some cases, strong utilization controls could offset this effect. We do not know if the utilization difference is due to actual treatment or billing differences. Further, we were unable to determine from the claims data if one specialty had better outcomes than the other. (+info)
The myths of emergency medical care access in the managed care era.
In this paper, we examine the perception that emergency care is unusually expensive. We discuss the myths that have fueled the ineffective and sometimes deleterious efforts to limit access to emergency care. We demonstrate the reasons why these efforts are seriously flawed and propose alternate strategies that aim to improve outcomes, including cooperative ventures between hospitals and managed care organizations. We challenge managed care organizations and healthcare providers to collaborate and lead the drive to improve the cost and clinical effectiveness of emergency care. (+info)
Monitoring patients with diabetes mellitus: an application of the probit model using managed care claims data.
The primary objective of this study was to estimate the likelihood of the use of either a glycosylated hemoglobin (HbA1c) test or an eye examination, or both, among a cohort of patients diagnosed with diabetes mellitus. A secondary objective was to provide a step-by-step discussion of the applicability of an econometric model to managed care organizations. The study used medical and pharmacy claims data from a managed care organization for the calendar year 1995. A probit regression model was specified to estimate the probability of occurrence for either an HbA1c test or an eye examination among patients with insulin-dependent, non-insulin dependent, or atypical/unclassified diabetes. Data were available only for patients under 65 years of age due to data truncation for patients covered by Medicare, resulting in a study sample size of 6,841. Results indicate that age, presence of hypertension, hyperlipidemia, multiple cardiovascular comorbidities, ophthalmic disease, and combinations of multiple commonly observed comorbidities were positively correlated with the probability of either HbA1c testing or eye examination. Gender and the type of benefit plan were not statistically significant as predictors of disease monitoring. A total of 1,860 patients with diabetes mellitus were predicted by the model to have undergone one of the two monitoring procedures; but in actuality, these patients were not monitored in 1995. They could be considered as high-risk patients who were not getting recommended monitoring. The probit model shows a predictive power of 64.48%. (+info)
Issues of medical necessity: a medical director's guide to good faith adjudication.
The term medical necessity is difficult to define, a problem for insurers who need to clearly describe what is and is not covered in their contracts with subscribers. An unclear, vague definition of medical necessity leaves insurers vulnerable to litigation by subscribers denied care deemed medically unnecessary. To avoid lawsuits, insurers must make every effort to educate their subscribers about their medical coverage, going beyond merely providing a lengthy subscriber handbook. In decisions on medical necessity, medical directors at insurance companies play a key role. They can bolster the insurer's position in denial-of-care cases in numerous ways, including keeping meticulous records, eliminating unreasonable financial incentives, maintaining a claims denial database, and consulting with other insurers to achieve a consensus on medical necessity. (+info)
Health-based payment and computerized patient record systems.
Health care information technology is changing rapidly and dramatically. A small but growing number of clinicians, especially those in staff and group model HMOs and hospital-affiliated practices, are automating their patient medical records in response to pressure to improve quality and reduce costs. Computerized patient record systems in HMOs track risks, diagnoses, patterns of care, and outcomes across large populations. These systems provide access to large amounts of clinical information; as a result, they are very useful for risk-adjusted or health-based payment. The next stage of evolution in health-based payment is to switch from fee-for-service (claims) to HMO technology in calculating risk coefficients. This will occur when HMOs accumulate data sets containing records on provider-defined disease episodes, with every service linked to its appropriate disease episode for millions of patients. Computerized patient record systems support clinically meaningful risk-assessment models and protect patients and medical groups from the effects of adverse selection. They also offer significant potential for improving quality of care. (+info)