Multiple Payers Research Articles

Complexities in Transplant Revenue Management

Numerous payment methodologies, contract types, and income reimbursement methods exist in the highly complex environment of transplantation. A fundamental understanding of the transplant environment and the various compensation schemes involved with transplant revenue management is necessary to stay viable in such a complicated system. Knowledge of resources such as Medicare, commercial insurance, Medicaid, and self-pay individuals will allow a program to fully optimize allowable revenue streams. This multiple payer mix can be challenging, with payment arrangements ranging from a single global case rate that must cover all transplant-related services to individual payment arrangements for each stage of the transplantation process. Transplant programs must track each agreement to ensure optimal payment, and must therefore become proficient with central fiscal operations such as Medicare cost reporting and managed care contract negotiations. Outlier protection and risk pool strategies can also be used to remain competitive and profitable. A transplant program must have a thorough understanding of all available payment schemes and reimbursement optimizing strategies to facilitate the realization of a strong financial outlook.

Complexities in transplant revenue management

Numerous payment methodologies, contract types, and income reimbursement methods exist in the highly complex environment of transplantation. A fundamental understanding of the transplant environment and the various compensation schemes involved with transplant revenue management is necessary to stay viable in such a complicated system. Knowledge of resources such as Medicare, commercial insurance, Medicaid, and self-pay individuals will allow a program to fully optimize allowable revenue streams. This multiple payer mix can be challenging, with payment arrangements ranging from a single global case rate that must cover all transplant-related services to individual payment arrangements for each stage of the transplantation process. Transplant programs must track each agreement to ensure optimal payment, and must therefore become proficient with central fiscal operations such as Medicare cost reporting and managed care contract negotiations. Outlier protection and risk pool strategies can also be used to remain competitive and profitable. A transplant program must have a thorough understanding of all available payment schemes and reimbursement optimizing strategies to facilitate the realization of a strong financial outlook.

The Massachusetts Health Plan: Public Insurance for the Poor, Private Insurance for the Wealthy, Self-Insurance for the Rest?

The Massachusetts Law for Providing Access to Affordable, Quality, Accountable Health Care represents one of the most ambitious attempts yet by one of the United States to reform its health care financing system.' It is useful, however, to situate this reform in the context of a larger discussion of health care financing reform that has been underway for some time. For at least the past quarter century, three visions of how to reform health care finance in the United States have competed for the allegiance of policy makers. The first of these visions calls for expansion of public insurance to achieve universal coverage, or something very close to it. 2 This model is often characterized as a single-payer model, although universal public coverage does not, of course, require a single payer. Many of the world's social insurance programs in fact have multiple payers.3 One way to achieve universal coverage through public insurance would be to expand the Medicare program to cover the entire population. Universal coverage, however, could also be achieved

Interpreting Change Scores of Tests and Measures Used in Physical Therapy

Over the past decade, the methods and science used to describe changes in outcomes of physical therapy services have become more refined. Recently, emphasis has been placed not only on changes beyond expected measurement error, but also on the identification of changes that make a real difference in the lives of patients and families. This article will highlight a case example of how to determine and interpret "clinically significant change" from both of these perspectives. The authors also examine how to use item maps within an item response theory model to enhance the interpretation of change at a content level. Recommendations are provided for physical therapists who are interpreting changes in the context of clinical practice, case reports, and intervention research. These recommendations include a greater application of indexes that help interpret the meaning of clinically significant change to multiple clinical, research, consumer, and payer communities.

Assessing the economic burden of asthma

Assessing the economic burden of asthma

Multiple payers, commonality and free-riding in health care: Medicare and private payers

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.

Risk sharing and the supply of mental health services

This paper examines the effects of risk sharing with mental health providers in a managed care context. The results show that providers that received a fixed payment per case reduced the number of outpatient visits by 20–25%, compared with providers who continued to be paid for each visit. This effect was stronger for integrated group practices and providers with more intensive utilization review protocols. In addition, evidence was found that in a setting where providers serve multiple payers, the share of their total revenue derived from risk-sharing contracts is an important determinant of the magnitude of the supply response.

Managed care for elderly people: a compendium of findings.

Although managed care seems to serve well the interests of non-elderly enrollees and their payers, elderly people face more risks. Chronic conditions, multiple problems, and more limited resources make them more vulnerable, whereas multiple payer sources make them more complicated to cover. This synthesis of managed care delivered in Medicare and Medicaid demonstration projects serving elderly beneficiaries shows that managed care plans either select or attract enrollees who suffer fewer frailties than those served in fee-for-service settings, exhibit reluctance to enter rural markets, provide a broad range of elderly-specific services, offer more comprehensive coverage and services, and result in greater perceived access problems, particularly for vulnerable subgroups. Plans operate more cheaply by using fewer resources, even after adjusting for case mix differences. Managed care enrollees tend to be more satisfied with financial and coverage aspects, whereas fee-for-service enrollees report higher satisfaction on other dimensions. In acute care settings, process of care findings were mixed, whereas clinical and self-reported outcome indicators were no better and in some instances worse in managed care. Long-term care enrollees, in the few studies reported, consistently faired worse in both the processes and outcomes of care. These findings suggest that further research on the effects of managed care in its rapidly changing incarnations is needed, particularly with respect to how to improve the quality of acute and long-term care delivered to elderly people and the proper role of government and other key actors in the health care system.

Volume responses to Medicare payment reductions with multiple payers: a test of the McGuire-Pauly model.

The effects of changing financial incentives on physician's practice behaviour have long been of interest to researchers and policy makers. We test a model of physician volume response within the context of multiple payers developed by Thomas McGuire and Mark Pauly. A panel data set covering discharges from about 200 hospitals in the US over 45 months is used to carry out the empirical investigation. A fixed-effect model with generalized least squares and instrumental variable specifications is used to compute empirical evidence of volume responses from eight specialties experiencing varying degrees of Medicare payment reductions following the implementation of Omnibus Budget Reconciliation Acts of 1989 and 1990. The empirical findings are compared with McGuire and Pauly's simulated predictions. We note that in examining physician responses to Medicare payment reductions in the context of a multi-payer environment, it becomes evident that only fixing one payer's reimbursement policy is at best a partial solution to cost containment. We echo observations made by other analysts that physician responses to payment changes can be quite complex. Physicians do not all respond to payment reduction in the same way.

Volume responses to medicare payment reductions with multiple payers: a test of the McGuire–Pauly model

The effects of changing financial incentives on physician's practice behaviour have long been of interest to researchers and policy makers. We test a model of physician volume response within the context of multiple payers developed by Thomas McGuire and Mark Pauly. A panel data set covering discharges from about 200 hospitals in the US over 45 months is used to carry out the empirical investigation. A fixed-effect model with generalized least squares and instrumental variable specifications is used to compute empirical evidence of volume responses from eight specialties experiencing varying degrees of Medicare payment reductions following the implementation of Omnibus Budget Reconciliation Acts of 1989 and 1990. The empirical findings are compared with McGuire and Pauly's simulated predictions. We note that in examining physician responses to Medicare payment reductions in the context of a multi-payer environment, it becomes evident that only fixing one payer's reimbursement policy is at best a partial solution to cost containment. We echo observations made by other analysts that physician responses to payment changes can be quite complex. Physicians do not all respond to payment reduction in the same way. © 1998 John Wiley & Sons, Ltd.

Payment source and the cost of hospital care: Evidence from a multiproduct cost function with multiple payers

This study investigates the capacity of hospitals to vary the intensity of their services based on patients' expected sources of payment. While the concept of price discrimination by hospitals based on payer generosity (“cost-shifting”) has been discussed extensively, the notion that hospitals can adjust payer-specific marginal costs to reflect differences in reimbursement policies has not been studied in depth. To examine this issue, this analysis employs a multiproduct cost function with hospital outputs defined as admissions by payment source, controlling for the distribution and severity of illness (“casemix”) for each payer. Marginal costs of casemix-adjusted discharges are obtained and compared for Medicare, Medicaid, Private Payers, and a residual category that includes uncompensated care. We find that indeed, payer-specific marginal costs generally reflect payer generosity.

Effect of recent health and social service policy reforms on Britain's mental health system.

The introduction of new policies in health and social services in Britain has changed the way community care is provided to seriously mentally ill people. Britain is creating the same problems that have existed in the United States, whereby clinicians struggle to provide services in an environment with multiple payers and perverse incentives. A simple system in Britain has been replaced with complicated organisational and financial structures that require almost impossible feats by local health and social service staff to coordinate care for patients for whom continuity of care is critical for their survival in the community and their wellbeing. Seriously mentally ill people are in the middle of these complicated problems. The creation of a local mental health authority that could be held responsible for community care, as exists in some American states, may be one solution.

Treating early-stage breast cancer: hospital characteristics associated with breast-conserving surgery.

Despite growing acceptance of the fact that women with early-stage breast cancer have similar outcomes with lumpectomy plus radiation as with mastectomy, many studies have revealed the uneven adoption of such breast-conserving surgery. Discharge data from the Hospital Cost and Utilization Project, representing multiple payers, locations, and hospital types, demonstrate increasing trends in breast-conserving surgery as a proportion of breast cancer surgeries from 1981 to 1987. Women with axillary node involvement were less likely to have a lumpectomy, even though consensus recommendations do not preclude this form of treatment when local metastases are present. Non-White race, urban hospital location, and hospital teaching were associated with an increased likelihood of having breast-conserving surgery.

Resident selection in a Connecticut nursing home. A view from within.

Using data from a year of participant observation, this study provides a detailed description of resident selection procedures in a for-profit Connecticut skilled nursing facility. A system of multiple payers for nursing home services created a hierarchy of admission preferences that privileged those who could pay and denied access to the least profitable and the sickest individuals. Prescreening and waiting list juggling were strategies employed by the home to maximize the selection of private-paying residents and residents requiring the least care.

Prospects for national health care in the United States.

This paper provides an overview of both the current health care crisis in the United States and various reform proposals (some based on Canadian and British models) being considered at the federal and state levels. The proposals discussed fall into three categories--multiple payer national health insurance programs, one payer national health insurance programs, and a national health service program. The authors review four important criteria (cost, quality, access, and equity) that must be considered in evaluating the proposals for reform. Information is provided to assist health care professionals in understanding the various national health care proposals, applying evaluative criteria to these proposals, and advocating for needed changes.

Physician response to fee changes with multiple payers

This paper develops a general model of physician behavior with demand inducement encompassing the two benchmark cases of profit maximization and target-income behavior. It is shown that when income effects are absent, physicians maximize profits, and when income effects are very strong, physicians seek a target income. The model is used to derive own and cross-price expressions for the response of physicians to fee changes in the realistic context of more than one payer under the alternative behavior assumptions of profit maximization and target income behavior. The implications for public and private fee policy, and empirical research on physician response to fees, are discussed.

An Outbreak of Hepatitis A among Cancer Patients Treated with Interleukin-2 and Lymphokine-Activated Killer Cells

An outbreak of hepatitis A virus (HAV) infection occurred among cancer patients treated with interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cells between July and September 1986 at six different clinical centers. Among 85 patients tested serologically for recent HAV infection, 22 (39%) of 56 susceptible patients developed acute HAV infection. Only exposure to LAK cells cultured in medium containing human serum from two specific manufactured pools was associated with HAV infection. Attack rates were 85% among patients exposed to pool X, 62% in patients exposed to pool Y, and 50% in those exposed to both pools, compared with none among the 24 susceptible persons exposed to other serum pools (P less than .001). The serum used in production of LAK cell medium was obtained from multiple paid donors. Twenty persons donated plasma to both serum pools X and Y. Although none of 12 donors tested had evidence of recent HAV infection, it is likely that an asymptomatic plasma donor viremic for HAV contaminated both serum pools and the LAK cell medium made from it.

The Economics of Long‐Term Care for the Mentally Ill

Systems of long‐term care for the mentally ill have been largely shaped by financing and reimbursement, rather than sound treatment principles. An undue emphasis on institutional care and the lack of coordination among providers can be attributed to perverse economic incentives and multiple payers. This article argues that, because of the special nature of long‐term psychiatric disabilities, there is a predictable underutilization of long‐term psychiatric services. It considers three types of settings: state hospitals, nursing homes, and community care, discussing current financing mechanisms in each. Finally, it presents characteristics of ideal systems and examines several proposed financing models according to these characteristics.

Recent Performance and Outlook for Petroleum Securities

Abstract The review of investor attitudes towards the petroleum industry during the 1950 decade reveals the fever-pitch attraction experienced in the mid-1950's and the period of selling in oil shares following the Suez crisis. In the last two and a half years, oil shares have experienced renewed interest on the part of the investment community. The growing demand for energy and petroleum should support an anticipated annual growth in oil demand of 5.6 per cent. The problems facing the industry, such as oversupply invasion of natural gas into oil markets, governmental demands, Russian exports, and internal industry competition are all discussed and placed in their proper perspective. A series of figures compares the earnings and dividend progress of domestic integrated a international oil companies with the Dow Jones 30 Industrial Companies. While gasoline price wars and weather cycles still influence earnings of many companies and, in fact, cause them to be somewhat cyclical, the economy measures employed by the larger oil companies in the post-Suez period support the expectation of an upward trend for earnings. Return on borrowed and invested capital has shown slight improvement since 1958. Though it is likely that some differential will continue between the multiple paid for oil earnings and that paid for the Dow-Jones industrial earnings, it is expected that oil earnings may well experience a higher multiple in the foreseeable future. The long range outlook for petroleum companies, particularly those with well diversified markets and supplies, is constructive. The well-guided investor should be amply rewarded in oil shares. Introduction During the early and mid-1950's, oils were one of the most favored investment media. It was during this period that the investor, both public and institutional, was captivated by the romance of discovery inherent in the oil industry. It was a seller's market for crude oil, which in the post war period had been enjoying periodic price increases, and demand for petroleum was growing at a rate well in excess of the general economy. Exploration and development activities were watched closely by the investment communities. In fact, during those years, maps of the Williston and Permian Basins and offshore areas of the Gulf of Mexico were almost as commonplace in some brokerage offices as charts of the Dow Jones averages. For the investor such interest did not go unrewarded. Stocks of oil companies, particularly straight producers, often experienced spectacular gains in a few days based on oil discovery news. The international oil companies and many integrated domestic companies, along with the so-called domestic producers, gave significantly better performance than the general stock market. To a degree, the performance was spectacular enough to somewhat spoil the investor. His illusions of grandeur led him to think of a proper oil investment being a stock which would double in price in no more than six months and one day, increase the dividend and possibly split the stock two-for one. Little nuisances inherent in the oil industry were put aside and dismissed as trivial although these same nuisance factors were at a later day to be used as arguments against investing in oil. Even political upheavals were taken in stride. In the period of 1950–55, the Dow Jones averages rose by 108 per cent. During that same period, most of the major oil company securities more than doubled. In fact, a number of these securities more than tripled. While some of the more spectacular rises were shown in some of the smaller producing companies, the larger and more traditional names also participated in this rise. During that period, the stock of Gulf Oil rose 140 per cent -- those of Standard Oil of New Jersey and Texaco tripled in price. The market price of oil shares discounted far in advance earnings that might be forthcoming from announced discoveries which sparked the rise in a security. For instance, Texas Gulf Producing stock rose from $13/share* at the beginning of 1954 to $31/share* at the beginning of 1955. Yet, predicted on developments in the Headley field, the earnings of the company were $1.43* in 1954, $1.72* in 1955, and back to $1.46* in 1956.Amerada, basking in the glory of oil discovery in the Williston Basin, was an outstanding investment. In terms of adjusted price for the stock splits that occurred since 1950, the stock rose from $20/share* at the beginning of 1951 to $58/share* by April, 1952. Yet, the earnings in 1951 were the equivalent of $1.30/ share* and in 1952 were $1.26/share.* JPT P. 633ˆ