A national inpatient cost estimate of percutaneous endoscopic gastrostomy (PEG)-associated aspiration pneumonia.
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OBJECTIVE: To present national estimates of the prevalence and costs of inpatient admissions for aspiration pneumonia (AP) associated with percutaneous endoscopic gastrostomies (PEGs) inserted before or during an admission. STUDY DESIGN: Retrospective analysis using medical claims. PATIENTS AND METHODS: National estimates of the prevalence of inpatient admissions associated with AP and mortality rates were developed, using data from the Nationwide Inpatient Sample of the Hospital Cost and Utilization Project (HCUP-3) Database. The MEDSTAT Group's MarketScan Private Pay Fee-for-Service (FFS) and Medicare FFS databases were used to calculate the percentage of admissions for AP that were preceded by a PEG or that entailed a PEG placement. Associated statistics, such as average length of stay and mean payments for these admissions, also were estimated. RESULTS: Approximately 300,000 inpatient admissions for AP took place in the United States in 1995, of which roughly 70,000 (23.9%) resulted in death. Approximately 10% of all AP admissions occurred after or entailed a PEG placement. After adjusting for differences in patients' age, gender, and health status, the total mean payments were estimated to be $26,618 per patient. This per-patient estimate translates into a national estimate of the cost of PEG-associated AP of approximately $808.2 million. CONCLUSION: The cost of PEG-associated AP is relatively high, as estimated in this study. The high inpatient mortality rates of AP imply that future efforts should be directed toward preventing AP. (+info)
Slovenian experience on health insurance (re)introduction.
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A period of changes in what had previously been public health insurance began in Slovenia in 1992. A new legislation introduced a mixed public-private insurance, the share of GDP allocated for health care insurance in Slovenia equaled the EU average, and the financing of the public health insurance has been balanced up - until now. For the first time since Slovenia gained independence, the compulsory health insurance is planning a 6% reduction in its income. The way to the solution of the problem lies in a political consensus on the public health issues in Slovenia, but it is still unclear whether it can be reached. A successful political agreement on the adequate amount of health care, granted to the Slovenian citizens by the public health insurance, should secure its balanced financing, which is about to be disturbed. (+info)
Medicaid managed care reimbursement for HIV and its implications for access to care.
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The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care. (+info)
Vaporware.com: the failed promise of the health care Internet.
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Contrary to the claims of its well-financed promoters, the Internet will not solve the administrative redundancies, economic inefficiencies, or quality problems that have plagued the U.S. health care system for decades. These phenomena are the result of economic, organizational, legal, regulatory, and cultural conflicts rooted in a health care system grown from hybrid public and private financing; cultural expectations of unlimited access to unlimited medical resources; and the use of third-party payers rewarded to constrain those expectations. The historic inadequacy of information technology to solve health care's biggest problems is a symptom of these structural realities, not their cause. With its revolution of information access for consumers, the Internet will exacerbate the cost and utilization problems of a health care system in which patients demand more, physicians are legally and economically motivated to supply more, and public and private purchasers are expected to pay the bills. (+info)
Association of resident coverage with cost, length of stay, and profitability at a community hospital.
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OBJECTIVE: The effect of care by medical residents on hospital length of stay (LOS), indirect costs, and reimbursement was last examined across a range of illnesses in 1981; the issue has never been examined at a community hospital. We studied resource utilization and reimbursement at a community hospital in relation to the involvement of medical residents. DESIGN: This nonrandomized observational study compared patients discharged from a general medicine teaching unit with those discharged from nonteaching general medical/surgical units. SETTING: A 620-bed community teaching hospital with a general medicine teaching unit (resident care) and several general medicine nonteaching units (no resident care). PATIENTS: All medical discharges between July 1998 and February 1999, excluding those from designated subspecialty and critical care units. MEASUREMENTS AND MAIN RESULTS: Endpoints included mean LOS in excess of expected LOS, mean cost in excess of expected mean payments, and mean profitability (payments minus total costs). Observed values were obtained from the hospital's database and expected values from a proprietary risk-cost adjustment program. No significant difference in LOS between 917 teaching-unit patients and 697 nonteaching patients was demonstrated. Costs averaged $3,178 (95% confidence interval (CI) +/- $489) less than expected among teaching-unit patients and $4,153 (95% CI +/- $422) less than expected among nonteaching-unit patients. Payments were significantly higher per patient on the teaching unit than on the nonteaching units, and as a result mean, profitability was higher: $848 (95% CI +/- $307) per hospitalization for teaching-unit patients and $451 (95% CI +/- $327) for patients on the nonteaching units. Teaching-unit patients of attendings who rarely admitted to the teaching unit (nonteaching attendings) generated an average profit of $1,299 (95% CI +/- $613), while nonteaching patients of nonteaching attendings generated an average profit of $208 (95% CI +/- $437). CONCLUSIONS: Resident care at our community teaching hospital was associated with significantly higher costs but also with higher payments and greater profitability. (+info)
Patients with cancer referred to hospice versus a bridge program: patient characteristics, needs for care, and survival.
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PURPOSE: The purpose of this study was to compare the characteristics and needs of patients with advanced cancer who were referred to hospice with those referred to a prehospice "bridge" program that is staffed by hospice nurses. PATIENTS AND METHODS: Data were gathered through retrospective review of computerized clinical records using precoded data fields of 284 patients with cancer enrolled in a bridge program and 1,000 who enrolled in a hospice program. Patient characteristics, needs for supportive care at the time of enrollment, and survival were assessed. RESULTS: Bridge patients were less likely to have Medicare or Medicaid (43% v 72%; odds ratio, 0.30; P <.001) and were younger (69 v 73 years, rank sum test; P <.001), more likely to be married (59% v 43%; odds ratio, 1.90; P <.001), and more likely to be in the highest income category (14% v 10%; odds ratio, 1.77; P =.009). Bridge patients had at least as many needs for care as did patients in hospice. Bridge patients lived significantly longer (median, 46 v 19 days; log-rank test of survivor functions, P <.001). CONCLUSION: Patients referred to this bridge program had prognoses that are significantly better than those of patients who enter hospice, but they have needs for supportive care that are at least as great. These findings underscore the importance of initiatives to extend some of the benefits of hospice care to a wider population of patients and should encourage the analysis of similar programs' ability to meet these needs. (+info)
Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores.
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BACKGROUND: The Department of Health introduced a new deprivation payments system for general practitioners (GPs) on 1 April 1999. Following a three-year phasing-in process, registered patients will attract deprivation payments based on the underprivileged area (UPA) score of their enumeration district (ED) of residence, rather than their electoral ward, changing the pattern and distribution of payments throughout England. AIM: To assess the rationale behind the changed deprivation payments system for GPs in England and to examine its impact on GP and practice payments. DESIGN OF STUDY: A quantitative study modelling practice-based deprivation payments. SETTING: A total of 25,450 unrestricted principal GPs in 8919 practices in England. METHOD: The effect of three new components in the system were examined: changes in the ED score ranges attracting payment, the percentage increase in the size of successive payment bands, and the total budget. The relationship between consultation rates (used as a proxy for workload) and UPA score was examined, together with changes in GP payments calculated nationally and by geographical area. RESULTS: A total of 11.6% of the population of England live in wards with a UPA score of 30 or more, qualifying for deprivation payments, and a similar proportion (11.4%) live in EDs with a UPA score of 20 or more. The larger percentage increases in the size of payments in successive ED UPA bands is supported by the modelled relationship between consultation rate and UPA score. Financially, under the new deprivations payment system, entitlement widens with 88% of practices receiving a payment. Overall, 74% of GPs gain and 13% lose (3% losing more than 1500 Pounds), with 13% receiving no payment. CONCLUSION: The new ED system maps onto the previous system well. Moreover, it more finely discriminates between smaller areas of different relative deprivation and, thereby, targets payments more accurately. (+info)
Physician organization in California: crisis and opportunity.
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Many of the 250 physician organizations that provide care to California's sixteen million health maintenance organization enrollees are in a state of crisis, squeezed between constrained revenues, rising practice costs, and consumer sentiment that favors unconstrained choice over integrated delivery. Medical groups and independent practice associations are retrenching to their core geographic areas, reducing capitation for drug benefits and hospital services, and abandoning dreams of displacing health plans. Consolidation is accelerating in some areas, as medical groups join with hospitals to extract higher payment rates from insurers and employers. The conjunction of consumerism and premium inflation creates new opportunities for organizations that truly can manage health care, but the challenges roiling California's medical groups may preclude meaningful efforts to seize the initiative. (+info)