Reimbursement Fees Research Articles

Public Goods vs. Market Failure: Politics of Fee Reimbursement Scheme in Andhra Pradesh

Public Goods vs. Market Failure: Politics of Fee Reimbursement Scheme in Andhra Pradesh

Break-even analysis of Medicaid vs fee for service in orthodontic practice: North Carolina as a case study

Access to orthodontic services for children enrolled in Medicaid is limited nationwide. Orthodontists cite low fee reimbursement as a significant barrier to Medicaid participation. The purpose of this study was to examine, under a specific set of practice assumptions, the simulated effect on profitability of treating patients covered by Medicaid in orthodontic practices in North Carolina by using a break-even analysis for the 2005 fiscal year. Questionnaires were mailed to 154 orthodontists in active practice in North Carolina. The response rate was 58%. Seventy respondents met the eligibility criteria. Respondents were categorized into 4 groups based on the number of 2005 Medicaid case starts (I, 0; II, 1-5; III, 6-12; IV, 13 or more). By using the aggregated responses for treatment fees, treatment times, and overhead percentages for each group, average per-patient costs were calculated for each group and used in a break-even analysis. Group I accounted for 60% of respondents; group II, 20%; group III, 9%; and group IV, 11%. Assuming that the break-even point had not been reached, the group I practice would have an average estimated loss of $164 per patient whereas groups II, III, and IV would realize average profits from $98 to $256. The break-even point increased slightly in groups I, II, and III after the total number of patients in the patient pool was increased by 5%, assuming that additional patients were enrolled in Medicaid: group I, 203 to 210; group II, 220 to 226; group III, 158 to 160. The break-even point for group IV was 234 patients. Assuming that the break-even point had been reached, all groups were estimated to realize average per-patient profits of $1483 to $1897. Break-even analysis is a basic economic concept applicable to orthodontic practices. Under the specific conditions of this study, the inclusion of 5% of patients enrolled in Medicaid in the active patient pool had minimal effect on the financial break-even point and, assuming that the break-even point had been reached, was unlikely to have a negative financial impact on the practice.

Barriers and Potential Solutions to Increasing Immunization Rates in Adolescents

The creation of the adolescent vaccine platform presents both opportunities and challenges. Many of the barriers to vaccinating adolescents are similar to those of vaccinating younger children. However, adolescents have additional issues, such as their rapidly changing emotional and cognitive development, which can shape their immunization receptivity. Adolescents' lower rates of contact with the healthcare system for both acute and preventive health care result in fewer immunization opportunities. Potential solutions to increase adolescent immunization rates include the following: first, further development of computerized immunization information systems that contain the complete immunization history and flag recommended immunizations. Second, widely adopting a single state middle/high school mandate for the adolescent immunization platform to bring adolescents in for immunizations, which could result in the fulfillment of all recommended immunizations. Finally, implementing proposed financing changes to better apply Vaccines for Children coverage, reimbursement and administration fees in the public sector, and changes to private health insurance plans coverage.

Direct Health Care Costs Associated with Asthma in British Columbia

A better understanding of health care costs associated with asthma would enable the estimation of the economic burden of this increasingly common disease. To determine the direct medical costs of asthma-related health care in British Columbia (BC). Administrative health care data from the BC Linked Health Database and PharmaNet database from 1996 to 2000 were analyzed for BC residents five to 55 years of age, including the billing information for physician visits, drug dispensations and hospital discharge records. A unit cost was assigned to physician/emergency department visits, and government reimbursement fees for prescribed medications were applied. The case mix method was used to calculate hospitalization costs. All costs were reported in inflation-adjusted 2006 Canadian dollars. Asthma resulted in $41,858,610 in annual health care-related costs during the study period ($331 per patient-year). The major cost component was medications, which accounted for 63.9% of total costs, followed by physician visits (18.3%) and hospitalization (17.8%). When broader definitions of asthma-related hospitalizations and physician visits were used, total costs increased to $56,114,574 annually ($444 per patient-year). There was a statistically significant decrease in the annual per patient cost of hospitalizations (P<0.01) over the study period. Asthma was poorly controlled in 63.5% of patients, with this group being responsible for 94% of asthma-related resource use. The economic burden of asthma is significant in BC, with the majority of the cost attributed to poor asthma control. Policy makers should investigate the reason for lack of proper asthma control and adjust their policies accordingly to improve asthma management.

A multi-product cost function for physician private practices

This paper provides an empirical analysis of the production of physician services using a multi-product cost function. Prior studies examine the physician production process in a theoretical setting and do not provide empirical insight. We expand upon the theoretical work in the literature by specifying a four-product generalized Leontief cost function for physician services that recovers measures of marginal cost, scale, scope, and elasticity. Our study is based on physician survey data from the 1998 American Medical Association Physician Socioeconomic Monitoring Survey and motivates a scientific framework for advancing the existing reimbursement fee schedule. Our analysis indicates that physician office visits are generally priced above marginal cost, implying there may be evidence of market power in physician private practices. Furthermore, our analysis lends to the policy debate over whether the use of a Resource-Based Relative Value Scale system is the most appropriate mechanism for facilitating Medicare reimbursements.

Costs of dialysis--a regional population-based analysis

Population-based estimates of costs of renal replacement therapy are scarce in the literature. The aim of our study was to calculate the costs of long-term dialysis in 2006 on the basis of patient-specific data from a well-defined population in a region in western Germany (n = 310,757). Cost estimation was performed from the perspective of the statutory health insurance. All dialysis patients from the study region (n = 344, 54% male, mean age (+/-SD) 69 +/- 13 years, 42% diabetic) were assessed for the costs of the dialysis procedures, dialysis-related hospital admissions, outpatient contacts outside of our dialysis center, dialysis-related medication, patient transportation and related costs (e.g. reimbursement fees on the basis of the German diagnosis-related group system, price scales). We estimated the cumulative cost per patient year in 2006 (in Euros), along with the 10th and 90th percentiles and the 95% confidence intervals (CI) by using bootstrapping procedures. The mean total dialysis-related cost in 2006 was 54,777 Euros (95% CI, 51,445-65,705) per patient year. The largest part of the costs (55%) was caused by the dialysis procedures, followed by the costs of medication (22%), hospitalization (14%) and transportation (8%). The total cost increased significantly with increasing age. No significant association was found between total cost and sex, dialysis strategy, end-stage renal disease duration and diabetes. We present for the first time a cost estimation of dialysis in Germany on the basis of patient-level data in a population-based sample. Except age, patient characteristics were not significantly associated with costs. The largest part of the costs was caused by the dialysis procedures themselves; however, other dialysis-specific health care utilization also strongly contributed to the total cost.

Adherence: a review of education, research, practice and policy in Switzerland.

this article describes what has been undertaken in the last decade in medication adherence in terms of education, research, practice and policy in Switzerland. Medline was searched, with the search limited to Switzerland. The three Swiss pharmacy schools were also contacted to collect information about the medication adherence content of both their courses and research programs. National policies related to medication adherence were also reviewed for relevant content. two pharmacy schools offer courses devoted specifically to medication adherence. The number of hours dedicated to the topic varies between 4 to13. a total of 16 studies met the inclusion criteria. Chronic patients were the focus of 9 studies. Medication adherence was the primary outcome of all studies; 10 studies also measured clinical outcomes. Nine studies evaluated the prevalence of medication nonadherence; three studies evaluated the feasibility of new technologies for monitoring adherence; three studies evaluated medication adherence enhancing programs. Policies: three cognitive pharmaceutical services are reimbursed by healthcare insurers, which are directly related to medication adherence. Pharmacists in Switzerland have been actively involved in medication adherence research since the mid '90s. Specific medication adherence courses have entered the curriculum of pharmacy schools, and policies in Switzerland are slowly beginning to meet needs of chronic patients by the introduction of pharmaceutical cognitive services and reimbursement fees.

Protecting Our Turf: What Can You as a Resident Do?

Over the past 7 months, I have taken time to study a number of issues that have serious ramifications for the future of radiology: turf wars, self-referral, increasing health care costs as a result of medical imaging, and the indiscriminate reduction of technical fee reimbursement imposed by the Deficit Reduction Act of 2005, to name a few. As I learned more about these topics, my first impulse was to go to the highest hills and scream out about the unethical practice of self-referral, the overutilization of medical imaging by nonradiologists, and the harmful radiation patients are exposed to with inappropriate imaging.

Costs of the detection of metastases and follow-up examinations in cutaneous melanoma

At present, no universally accepted recommendations exist for cutaneous melanoma follow-up. Various surveillance strategies, some associated with significant cost, others of uncertain value, are routinely used. This study aimed to evaluate of the costs incurred for varied surveillance strategies practiced in Europe and the USA. One thousand nine hundred and sixty-nine cutaneous melanoma patients with stage I-III disease attending the Department of Dermatology, University of Tuebingen for follow-up between 1996 and 1998 participated in the study. Routine surveillance consisted of cutaneous examination, lymph node and abdomen sonography, chest radiograph (CR) and blood tests. The costs incurred were based upon the 2004 German official scale for medical reimbursement and the 2004 Medicare fee reimbursement schedule (USA). The total charges were based on the number of recurrences detected per stage. Recurrences were detected in 1.5% of patients with stage I, 18.0% in stage II, and 68.6% in stage III. Physical examination was the most effective method, detecting 50.0% of recurrences. Lymph node sonography was effective in stage II-III, detecting 13.2% of recurrences; CR and abdominal sonography, detecting 4.5 and 3.4% of recurrences, were deemed beneficial in stage III. Blood tests detected 1.4% of recurrences and were deemed to be ineffective. Computed tomography scans were valuable in clarifying ambiguous findings and helping to detect 22.5% of recurrences (1.9% in stage I, 1.9% in stage II, and 18.6% in stage III). A risk-adapted surveillance strategy for stage I-II including thorough history, physical examination and lymph node sonography but omitting CR, blood work and abdomen sonography, seems appropriate and cost effective.

Genetic Testing Before Serologic Screening in Relatives of Patients With Celiac Disease as a Cost Containment Method

Relatives of patients with celiac disease have an increased lifetime risk of developing celiac disease. Repeat screening of relatives would improve diagnosis rates, but at significant cost. Genetic testing before screening would potentially reduce costs by eliminating HLA-DQ2 and DQ8 negative patients who are at extremely low risk for developing celiac disease. A decision tree was developed incorporating 3 diagnostic branches: initial screening with anti-tissue transglutaminase at time t0, repeat screening at time t1, and genetic testing before repeat screening. Costs were estimated using Medicare reimbursement fees. Modeling and sensitivity analyses were performed using Tree Age Pro 2006. The cost of an initial screening with anti-tissue transglutaminase is approximately $434 per person. Repeat screening would cost $683, but would diagnosis an additional 4.4% cases. Genetic testing before screening would cost $750, but would decrease the lower endoscopy workload by nearly 25%. Genetic testing would have to decrease from $301 to $234, a difference of $67, to justify its use before serologic testing. As the specificity of anti-tissue transglutaminase approaches 100%, the cost of genetic testing would have to continue to decrease to less than $200 in order for it to be an affordable option. Repeat screening of relatives with celiac disease results in a significant increase in cost, but also an associated increase in cases diagnosed. Genetic testing would potentially eliminate up to 60% of the population to be screened and, if available at a lower cost, would partially offset costs of repeat serologic screening.

A microcosting study of diagnostic tests for the detection of coronary artery disease in the Netherlands

Objective The primary aim of the present study was to calculate the actual costs of four diagnostic tests for the detection of coronary artery disease in the Netherlands using a microcosting methodology. As a secondary objective, the cost effectiveness of eight diagnostic strategies was examined, using microcosting and reimbursement fees subsequently as the cost estimate. Design A multicenter, retrospective cost analysis from a hospital perspective. Setting The study was conducted in three general hospitals in the Netherlands for 2006. Interventions Exercise electrocardiography (exECG), stress echocardiography (sECHO), single-photon emission computed tomography (SPECT) and coronary angiography (CA). Results The actual costs of exECG, sECHO, SPECT and CA were €33, 216, 614 and 1300 respectively. For all diagnostic tests, labour and indirect cost components (overheads and capital) together accounted for over 75% of the total costs. Consumables played a relatively important role in SPECT (14%). Hotel and nutrition were only applicable to SPECT and CA. Diagnostic services were solely performed for CA, but their costs were negligible (2%). Using microcosting estimates, exECG–sECHO–SPECT–CA was the most and CA the least cost effective strategy (€397 and 1302 per accurately diagnosed patient). Using reimbursement fees, exECG–sECHO–CA was most and SPECT–CA least cost effective (€147 and 567 per accurately diagnosed patient). Conclusions The use of microcosting estimates instead of reimbursement fees led to different conclusions regarding the relative cost effectiveness of alternative strategies.

What Is Your Radiologist Assistant Student Worth to You?

To associate a monetary value with the productivity of a radiologist assistant (RA) student during the educational process, as a predictor of the potential impact on radiology practices acting as preceptors to RA students. Eight RA students' productivity was analyzed using preexisting data composed of a list of examinations completed as part of the educational process. The Institutional Review Board at the University of Arkansas for Medical Sciences classified this study as exempt. The data were correlated with current Centers for Medicare and Medicaid Services reimbursement rates. Analyses included descriptive statistical tests for the sum of the amount of potential reimbursement calculated for each student and the mean and median for the study sample. The results conservatively predict the productivity of an RA student. The average number of procedures performed by the RA students was 581 during the minimum of 1,500 clinical internship hours. The average potential professional fee reimbursement for the procedures performed by the RA students during the educational process was $58,957. Unless radiology practices increase their capacity to handle larger volumes of examinations, the risk of losing business to others is likely to persist. By performing varying radiologic procedures, RAs can help address workforce shortages in radiology. Radiologist assistants enable radiologists to increase practice productivity by lessening the burden placed on radiologists, which permits radiologists to spend more time on image interpretations. The potential reimbursement produced by RA students is worth the time and effort invested by radiologists during the educational process.

Costs and prices of single dental fillings in Europe: a micro-costing study

Dental fillings represent an established procedure to treat tooth decay. The present paper provides a cost comparison of dental filling procedures across nine European countries. More specifically, the paper aims to estimate the costs and prices (i.e. reimbursement fees) of a single dental filling procedure in an approximately 12-year-old child with a toothache in a lower molar who presents at a dental practice, as described in a case vignette. Both amalgam and composite fillings were examined. Total costs were determined by identifying resource use and unit costs for the following cost components: diagnostic procedures, labour, materials, drugs, and overheads. Altogether, 49 practices provided data for the cost calculations. Mean total costs per country varied considerably, ranging from 8 euros to 156 euros. Labour costs were the most important cost driver in all practices, comprising 58% of total costs. Overhead costs were the second-most important cost component in the majority of countries. Actual cost differences across practices within countries were relatively small. Cost variations between countries were primarily due to differences in unit costs, especially for labour and overheads, and only to a lesser extent to differences in resource use. Finally, cost estimates for a single dental filling procedure based on reimbursement fees led to an underestimation of the total costs by approximately 50%.

Aligning Academic and Clinical Missions Through an Integrated Funds-Flow Allocation Process

Although much has been written about implementing mission-based management tools to help facilitate managing the primary academic missions at academic medical centers, there is surprisingly little written on standardized methodologies to align financial support across the academic and clinical missions. However, professional fee reimbursement has not kept pace with costs, and this, combined with potential decreases in research funding associated with the reductions in National Institutes of Health funding, creates additional financial challenges for academic clinical departments that do not share in technical fee reimbursement. As an integrated academic health system, the University of Pennsylvania School of Medicine and Health System recently took the opportunity to broadly restructure funds-flow opportunities, so as to help align the strategic goals across all of the clinical department activities.

Genetic Testing Prior to Serologic Screening in Family Members of Patients with Celiac Disease as a Cost Containment Method

Purpose: Family members of patients with celiac disease (CD) have increased rates of developing CD over their lifetime, with up to 3% seroconverting 5 years after an initial negative result. Repeat testing of family members 5 years later would improve CD diagnosis rates, but at significant cost. Genetic testing prior to screening family members for CD would potentially reduce these screening costs by eliminating HLA-DQ2 and DQ8 negative patients who are at extremely low risk for developing CD. Methods: Decision analysis was used to compare the costs of screening family members of patients with CD. The decision tree incorporated three diagnostic branches: initial screening with anti-tissue transglutaminase (tTG), repeat screening with tTG at 5 years later, and genetic testing prior to screening with tTG. Costs were estimated using Medicare reimbursement fees. Modeling and sensitivity analyses were performed using Tree Age Pro 2006 (Williamstown, MA). Results: The cost of an initial screening with tTG of family members of patients with CD is approximately $434 per person. Repeat screening at 5 years later would cost $683 per person, which is an additional $249, but would diagnosis an additional 4.4% cases of CD. Genetic testing prior to screening family members would be slightly more costly, at $750 per person, but would lower endoscopy workload by nearly 25% when compared to repeat screening at 5 years without genetic testing. The cost of genetic testing would have to decrease from $301.40 to $234.40, a difference of $67, to justify its use prior to serologic testing. As the specificity of tTG approaches 100%, the cost of genetic testing would have to continue to decrease to less than $200 in order for it to be an affordable option. Conclusion: Repeat screening with tTG of family members of patients with CD results in a significant increase in cost, but also an associated increase in CD cases diagnosed. Genetic testing would potentially eliminate up to 60% of the population to be screened and, if available at a lower cost, would partially offset costs of repeat serologic screening.

The North Carolina Medicaid Program: Participation and perceptions among practicing orthodontists

Limited provider participation in the Medicaid program is a barrier to access to orthodontic care for Medicaid-eligible patients. The goals of this study were to determine the participation level of North Carolina (NC) orthodontists in the Medicaid program, to examine NC orthodontists' perceptions of the Medicaid program and its beneficiaries, and to determine whether there are differences between practitioners who do and do not accept Medicaid patients. Questionnaires were mailed to all active orthodontists (n = 203) as reported in the NC State Dental Board of Licensing Section of the NC Health Professions Data System. Respondents were categorized as current Medicaid providers, past Medicaid providers, or orthodontists who have never accepted Medicaid. Forty of 166 respondents were current Medicaid providers, 33 were past providers, and 93 never accepted Medicaid patients. All 3 groups thought that low fee reimbursement is a major problem. Those who have never participated in the Medicaid program were more likely to perceive each barrier as a major problem. Past Medicaid providers saw broken appointments and tardiness to appointments as greater problems than current providers. Perceptions of Medicaid patients and lack of knowledge appear to be major barriers to provider participation.

New Mexico Insures Hearing Aids for Children: Advocacy Results in Success

New Mexico Insures Hearing Aids for Children: Advocacy Results in Success

Stepwise treatment paradigm for congenital nasolacrimal duct obstruction

This article is a retrospective, interventional case series involving 127 children who underwent stepwise treatment for congenital nasolacrimal duct obstruction. Initial treatment consisted of nasolacrimal probing, which was successful in 134 of 173 (77%) cases. The next step was balloon dacryoplasty, which was performed in all 39 probing failures. Thirty-two of 39 (82%) were cured. The remaining seven patients who failed both previous interventions underwent silicone intubation; all were cured. No patient required dacrycystorhinostomy. Success was defined as complete resolution of signs and symptoms of lacrimal obstruction, with the exception of occasional overflow tearing in the presence of noxious stimuli or while crying. In addition to describing a logical sequence of treatment, the authors performed a cost analysis based on reimbursement rates from Blue Cross/Blue Shield for the upstate New York area. Total costs, including facility fee charges for lacrimal probing, was $1,432; for balloon dacryoplasty, $1,883, and for silicone intubation, $2,046. Based on the number of children requiring more than one procedure, the average cost per cured lacrimal system was $1,939. The authors note that their reimbursement rates do not include cost of the Lacricath equipment or silicone tubes, since these are included in the facility fee reimbursement. The principal weakness of the authors’ analysis is the failure to include office probing as part of their treatment paradigm. While it has some limitations, office probing can be a quick, easy, and low-cost alternative for many patients less than 1 year of age. Therefore, the actual costs per cured lacrimal system may actually be less in practices using this approach.

Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement

Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting. We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders. A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement. The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.

Cost Analysis of Tumor Downsizing for Hepatocellular Carcinoma Liver Transplant Candidates

We report the results of a prospective, intent-to-treat (ITT) trial on the costs of selective tumor downsizing (DS) before liver transplantation (LT) for patients affected with hepatocellular carcinoma (HCC). The trial started in January 1997 including adult patients with nodular-type HCC within and beyond the Milan criteria. Patients were downsized with transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI) and/or radiofrequency ablation (RFA) according to clinical predictors. TACE and RFA were performed as inpatient procedures, while PEI was performed on an outpatient basis. Costs of DS were obtained according to the Tuscany Health Reimbursement Fee Catalog adjusted to yearly inflation rates from 1997 through 2005. Data analysis was performed at 1 year after the last enrollment of 198 patients, including 161 (81.3%) who were transplanted: 34 (17.2%) dropped out and 3 (1.5%) were still on the waiting list. One hundred and fifty-two patients (76.7%) underwent DS for a total of 201 procedures: 159 TACE, 39 PEI, and 3 RFA. Overall costs in Euros (€) of waitlisting were 861,801.24€: 548,460€ (63.7%) for pretransplantation evaluation; 197,994.84€ (22.9%) for control visits and hospitalizations; and 115.346.4€ (13.4%) for DS. Mean costs of DS were 758.58€ ± 270€ per downstaged patient (747.53€ ± 257.1€ Milan; 774.01€ ± 287.71€ non-Milan); 582.85€ ± 398.87€ per waitlisted patient (520.28€ ± 406.23€ Milan; 520.28 ± 364.48€ non-Milan); and 716.4€ per transplanted patient (580.67€ Milan; 1026.76€ non-Milan; +76.8%). A selective policy of tumor DS increased the costs of LT waitlisting by 13.4%, but due to higher dropout rates among non-Milan patients, the cost utility of DS was 76.8% higher in the Milan group.