Reimbursement Patterns Research Articles

Feasability of a Rapid Diagnostic Protocol for an Emergency Department Chest Pain Unit

See related editorial, p 168. Study objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model. Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12- hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion. Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%). Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns. [Zalenski RJ, Rydman RJ, McCarren M, Roberts RR, Jovanovic B, Das K, Mensah EK, Kampe LM: Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit. Ann Emerg Med January 1997;29:99-108.]

Hospice and minorities: a national study of organizational access and practice.

Hospices in the U.S. were surveyed in 1990 to find out whether service to blacks and Hispanics was affected by admission criteria and hospice service characteristics of hospices located in or near these populations. Hospice characteristics such as reimbursement patterns, staff interventions, and admission criteria were different depending upon the percent of blacks and/or Hispanics in the hospice service area or actually served by the hospice. Care for Hispanics was more dependent on Medicaid and free care than blacks whose care was financed primarily by Medicare and Medicaid. Hospices identified problems in serving Hispanics as language, reimbursement, and severity-of-illness issues. Hospice admission criteria, especially the primary caregiver requirement, were identified as impeding access for blacks. Hispanics were perceived as presenting the most access and service problems and as the most underserved.

Costs and benefits of outpatient therapy.

In recent years, much of the care traditionally rendered in hospitals has been shifted to ambulatory settings. This change has been fueled as much by changing patterns of reimbursement as by rapid developments in medicine and technology. The current climate of health-care reform suggests that this trend will continue for the near future. Unfortunately, there are few studies that systematically evaluate the cost effectiveness or benefits of ambulatory care. Among the few such studies published to date, the results are not overwhelmingly positive. While the monetary costs of ambulatory care are generally far lower than inpatient management, several studies suggest that family and household disruption are prominent features of outpatient strategies. Thus, the measurement of the direct and indirect costs and benefits of ambulatory treatment presents a significant challenge to researchers. Development of methodologies to support such studies must be among our highest priorities.

Legal approaches to the restraint of trade of nurse practitioners: disparate reimbursement patterns.

Nurse practitioners (NPs) can face, and have faced, several challenges in the health care environment. As with the denial of hospital admitting or staff privileges, the granting of inequitable reimbursement levels by state administrative bodies, physicians, insurers, and other members of the health care community may limit NP practice. Several strategies are discussed that will demonstrate how nurse practitioners can use legal and administrative mechanisms (e.g., antitrust laws) to eliminate restraints of trade and assure the availability of more equitable direct reimbursement patterns.

Con: Pulmonary artery catheters are not routinely indicated in patients undergoing elective abdominal aortic reconstruction

Con: Pulmonary artery catheters are not routinely indicated in patients undergoing elective abdominal aortic reconstruction

Reimbursement patterns in a hospital-based fixed-wing aeromedical service.

Reimbursement, expressed as a percentage of total charges recovered, was examined for inpatients transported by a university hospital-based, dedicated, fixed-wing aeromedical service between July 1, 1988 and June 30, 1990. A total of 410 patients were transported; account information was available for 404 patients (98%). Patients transported from in-state institutions (n = 174) had a hospital reimbursement rate of 53.3%, whereas the flight program recovered 46.1% of transportation charges. Patients transported from out-of-state institutions (n = 150) had a hospital reimbursement rate of 51.3%, whereas the flight program recovered 69.3% of charges. More patients referred from in-state sources were covered by Medicaid than from out-of-state sources (31% vs 11%), and less were covered by Medicare (17% vs 30%). Reimbursement for hospital charges was low for patients covered by Medicaid (44% for in-state and 16% for out-of-state), and Medicaid reimbursed no flight charges for either in-state or out-of-state patients. The flight program recovered 86.7% of charges for "triangle" flights, which transported patients between two hospitals other than the sponsoring institution (n = 80). The overall hospital reimbursement rate for inpatients was 70% during the study period. The flight program recovered 53.7% of its operating costs from payment of charges for transport services. Aeromedically transported patients may represent a financial "high-risk" group of patients for the sponsoring institution.

A coordinated approach to home infusion care.

Home intensive care can now be delivered in the patient's home. The growth of this clinical setting has been attributed to aging, an increase in technology, and national reimbursement patterns. Institutional nurses must anticipate and meet the patient's need for education and training specific to the therapeutic treatment to be provided at home, especially in the case of the acutely ill patient requiring home infusion therapy. Thus our technologically advanced system demands a coordinated approach.

The Business of Medicine

ABSTRACT This is a well-written compilation of practice information for the physician who wants to understand reimbursement options and how to evaluate practice options, to establish and manage a medical practice successfully using advisers, and to survive the frustrations and stresses of a physician's life. Gary Gitnick, MD, professor of medicine at UCLA School of Medicine at Los Angeles, has brought together a team of 53 experts who provide a wealth of information in a well-organized text.The first of five sections is an overview of the changing market forces impacting on the physician's practice. It reviews the changes in physician reimbursement patterns since 1900. Accompanying the changes from fee-for-service to the various third-party mechanisms of payment is the involvement of hospitals, government, group practices, the American Medical Association, and the recent alphabet soup of managed care. This trend analysis, primarily from the physician reimbursement standpoint, gives the reader a basis

Nosocomial pneumonia in Medicare patients. Hospital costs and reimbursement patterns under the prospective payment system

To determine the extent to which hospitals are reimbursed for Medicare patients who develop nosocomial pneumonia, we analyzed hospital accounting costs, reimbursements received, and the net income from 33 Medicare patients who developed nosocomial pneumonia. In 31 of the 33 cases, hospital costs for the entire admission exceeded reimbursements, with a median net loss of $5800 per case. Eleven randomly selected pneumonia cases were compared with control patients matched by diagnosis related group, age, sex, and service. Cases had significantly longer hospital stays, had greater total hospital costs, and caused greater net losses than did matched controls. We conclude that hospitals are seldom reimbursed adequately for Medicare patients who develop nosocomial pneumonia. With the advent of the prospective payment system, hospitals now have substantial financial incentives for implementing cost-effective measures for preventing nosocomial pneumonias.

The Adequacy of Physician Reimbursement for Pediatric Care Under Medicaid

This article examines 1989 Medicaid physician reimbursement for pediatric care in 47 states and the District of Columbia. To assess the adequacy of payment, several state reimbursement policies were analyzed, including physician payment methods, frequency of payment updates, and fee data for five common evaluation and management codes and two Early and Periodic Screening, Diagnosis, and Treatment visit categories. Physician payment rates were evaluated to determine overall state and regional patterns of Medicaid reimbursement. They were also compared with regional private market fee data and average national Medicare fees to assess their adequacy. The majority of state Medicaid programs used fixed fee schedules as their physician reimbursement method. Nearly one fourth of states that update their fees overall by physician specialty have not adjusted their rates since 1985 or before. Medicaid reimbursement rates for five commonly used evaluation and management Physicians' Current Procedural Terminology (4th ed) office visit codes and Early and Periodic Screening, Diagnosis, and Treatment screening and follow-up examinations varied substantially across states and among regions. States in the West paid the highest rates for most office visits, while Northeastern states generally paid the least. A comparison of Medicaid payment rates with private market fee data revealed that Medicaid payments for established patients averaged less than two thirds of market rates for pediatricians, family physicians, and general practitioners. New patient care is reimbursed somewhat better. Regional variations are substantial. In addition, a comparison of Medicaid payment rates with 1988 Medicare fee data showed that average Medicaid reimbursement rates were less than four fifths of average allowed Medicare charges. Policy implications include the need to increase Medicaid rates so that they are much closer to private insurance and Medicare rates, particularly in the Northeast and in selected states, in order to increase participation by pediatric providers in Medicaid. In addition, efforts to re-evaluate reimbursement relative to level of service, as used in Medicare's resource-based relative value scales, deserve further research. Finally, comparable access to comprehensive pediatric care especially in underserved urban areas will require not only improvements in physician reimbursement but also more deliberate efforts to affect the maldistribution of mainstream medical care. Approaches to measure the impact of enhanced reimbursement on access to care by Medicaid-eligible children are discussed.

Information Needs in Home Care: A Review and Analysis

Before prospective payment can be implemented in home care, providers and administrators in home care agencies require information in a variety of areas. This article reviews the literature on several factors likely to influence the market for home care services, including hospital use trends, the response to diagnosis-related groups by home care agencies, proposed reimbursement patterns, patient disease and demographic profiles, and patient needs. Research must be conducted in several areas before prospective payment can be implemented in home care.

Hospital Reimbursement Patterns Among Patients With Surgical Wound Infections Following Open Heart Surgery

Of the more than 200,000 patients who undergo open heart surgery annually in the United States, 2% to 10% will develop a post-operative infection related to their surgery. The economic impact of such infections on hospitals under the prospective payment system is unclear. To study the effect of such infections on hospital costs and reimbursement patterns, we compared case patients with controls of similar age, sex, urgency of surgery and type of surgery. The postoperative stay for cases was significantly longer than for matched controls (26.8 days and 8.3 days, respectively; p = .0002). The mean hospital cost for case admissions ($25,957) was twice as high as for control admissions ($12,795) (p = .0002). Cases resulted in an average net loss to the hospital of $2,344 per patient, while controls yielded an average net gain of $3,196 per patient (p = .02). We conclude that hospitals have substantial financial incentives to minimize the incidence of postoperative wound infections associated with open heart surgery.

Hospital Reimbursement Patterns among Patients with Surgical Wound Infections following Open Heart Surgery

Hospital Reimbursement Patterns among Patients with Surgical Wound Infections following Open Heart Surgery

Changes in Medicare Reimbursement for Echocardiographic Procedures

Medicare reimbursement for echocardiographic procedures is clouded by the fact that Medicare defines ultrasound services to be "radiologic." As such, a 40% limitation has been imposed in some states. In addition, as a result of the Omnibus Budget Reconciliation Act of 1987, a new radiology fee structure was negotiated with Medicare, without the input of internists and cardiologists, that may significantly affect reimbursement patterns for echocardiographic services. Those who perform and interpret cardiac ultrasound studies are again urged to use the medicine codes (90,000 series) rather than radiology codes (70,000 series).

The Challenge of Teaching Occupational and Environmental Medicine in Internal Medicine Residencies

Using a mailed survey questionnaire directed toward division chiefs of general internal medicine, we have confirmed that despite increased interest among faculty, few medical residents currently receive required or elective training in occupational medicine. However, recent changes in societal perceptions about environmental risks, corporate health care practices, and medical reimbursement patterns favoring provision by hospitals of contractual outpatient services to healthy workers all portend expanded involvement of residents in certain occupational medicine activities in the future, in response to economic pressures on both consumers and providers. These same forces may, unfortunately, undermine the scientific and ethical quality of such training experiences, compared with emerging, more academically motivated approaches. The implications of these prospects are analyzed in the hope that a proper balance can ultimately be struck between economic and academic imperatives.

The evolving subspecialization of psychiatry: implications for the profession.

Psychiatry is likely to evolve into a number of subspecialty areas, paralleling developments in other medical specialties. These changes are impelled both from within psychiatry, where the rapid increase in knowledge and skills makes mastery of the entire field by any one practitioner less possible, and from without, related to new expectations for psychiatric services from referral sources and patients, increasing competition by other physicians and nonphysician mental health care providers, and shifting reimbursement patterns. The authors discuss the advantages and disadvantages of subspecialization as well as implications for psychiatric practitioners and training programs.

Regulatory Considerations in the Establishment and Expansion of Office-Based Laboratories

As a result of changing patterns of medical practice, technology, and reimbursement, office-based clinical laboratory testing is increasing substantially. This article reviews current federal and state regulations covering such laboratories and comments upon likely trends in these regulations. Various economic and political issues associated with office-based clinical laboratory regulation are also discussed.

Iatrogenic Hand Injuries in Outpatients

Potentially serious iatrogenic hand injuries occurred in three patients in a general medicine practice. All resulted from technologic advances in patient care. Each resulted in substantial economic and emotional costs. One patient sustained a serious residual disability. Such injuries have rarely been reported in the past, but advances in medical technology and changes in reimbursement patterns may make outpatient iatrogenic hand injuries increasingly common. Physicians must be alert to such injuries.

Satelliting physical therapy into the community-an alternative approach to outpatient care

Changes in third-party reimbursement patterns such as the prospective reimbursement system recently implemented for Medicare patients, coupled with the rapid emergence of health maintenance organisations and preferred provider groups, have caused a shift in the location and under what provisions physical therapy is provided. Emphasis has been placed on outpatient services to some extent due to a mandated decrease in length of stay in acute care settings.For the past 7 years, McLaren General Hospital has operated three satellite units, providing a multi-disciplinary program to patients in their communities. This established network has provided our department with an alternative in appropriately addressing shifts in health care. At the same time, it has significantly increased our patient services.Criteria is presented to assist the therapist in evaluating the need for and placement of such a satellite unit, and the methodology, structure, and staffing patterns we have found necessary to appropriately addr...

Methodological issues and policy implications of physician manpower forecasting

Future physician supply is a matter of concern in most industrialized countries due to its impact on cost and quality of health care. Consequently, forecasting the number of physicians becomes an important research issue from both methodological and policy perspectives. This article presents a simple forecast model developed for the State of Wisconsin (U.S.A.), using the complex federal model of the U.S. Graduate Medical Education National Advisory Committee as a backdrop. In this context, the article discusses the main determinants of physician supply, such as mobility, retention, ageing and productivity. The methodological issues in the simple modelling of such phenomena are examined using the Wisconsin case as an empirical example. Finally, policy implications of planning physician supply with respect to projected demand for services, changes in reimbursement patterns and productivity are discussed along with some of the recommendations actually made to the Wisconsin Legislature.