Consumer credit as a novel marker for economic burden and health after cancer in a diverse population of breast cancer survivors in the USA.

BACKGROUND: Consumer credit may reflect financial hardship that patients face due to cancer treatment, which in turn may impact ability to manage health after cancer; however, credit's relationship to economic burden and health after cancer has not been evaluated. METHODS: From May to September 2015, 123 women with a history of breast cancer residing in Pennsylvania or New Jersey completed a cross-sectional survey of demographics, socioeconomic position, comorbidities, SF-12 self-rated health, economic burden since cancer diagnosis, psychosocial stress, and self-reported (poor to excellent) credit quality. Ordinal logistic regression evaluated credit's contribution to economic burden and self-rated health. RESULTS: Mean respondent age was 64 years. Mean year from diagnosis was 11.5. Forty percent of respondents were Black or Other and 60% were White. Twenty-four percent self-reported poor credit, and 76% reported good to excellent credit quality. In adjusted models, changing income, using savings, borrowing money, and being unable to purchase a health need since cancer were associated with poorer credit. Better credit was associated with 7.72 ([1.22, 14.20], p = 0.02) higher physical health t-score, and a - 2.00 ([- 3.92, - 0.09], p = 0.04) point change in psychosocial stress. CONCLUSIONS: This exploratory analysis establishes the premise for consumer credit as a marker of economic burden and health for breast cancer survivors. Future work should validate these findings in larger samples and for other health conditions. IMPLICATIONS FOR CANCER SURVIVORS: Stabilizing and monitoring consumer credit may be a potential intervention point for mitigating economic burden after breast cancer.

Variation in outpatient consultant physician fees in Australia by specialty and state and territory.

OBJECTIVES: To determine the mean, median and 10th and 90th percentile levels of fees and out-of-pocket costs to the patient for an initial consultation with a consultant physician; to determine any differences in fees and bulk-billing rates between specialties and between states and territories. DESIGN, PARTICIPANTS AND SETTING: Analysis of 2015 Medicare claims data for an initial outpatient appointment with a consultant physician (Item 110) in 11 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, geriatric medicine, haematology, immunology/allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). MAIN OUTCOME MEASURES: Mean, median, 10th and 90th percentile levels for consultant physician fees and out-of-pocket costs, by medical specialty and state or territory; bulk-billing rate, by medical specialty and state/territory. RESULTS: Bulk-billing rates varied between specialties, with only haematology and medical oncology bulk-billing more than half of initial consultations. Bulk-billing rates also varied between states and territories, with rates in the Northern Territory (76%) nearly double those elsewhere. Most private consultations require a significant out-of-pocket payment by the patient, and these payments varied more than fivefold in some specialties. CONCLUSION: Without data on quality of care in private outpatient services, the rationale for the marked variations in fees within specialties is unknown. As insurers are prohibited from providing cover for the costs of outpatient care, the impact of out-of-pocket payments on access to private specialist care is unknown.

Medical Debt and Related Financial Consequences Among Older African American and White Adults.

OBJECTIVES: To evaluate African American-White differences in medical debt among older adults and the extent to which economic and health factors explained these. METHODS: We used nationally representative data from the 2007 and 2010 US Health Tracking Household Survey (n = 5838) and computed population-based estimates of medical debt attributable to economic and health factors with adjustment for age, gender, marital status, and education. RESULTS: African Americans had 2.6 times higher odds of medical debt (odds ratio = 2.62; 95% confidence interval = 1.85, 3.72) than did Whites. Health status explained 22.8% of the observed disparity, and income and insurance explained 19.4%. These factors combined explained 42.4% of the observed disparity. In addition, African Americans were more likely to be contacted by a collection agency and to borrow money because of medical debt, whereas Whites were more likely to use savings. CONCLUSIONS: African Americans incur substantial medical debt compared with Whites, and more than 40% of this is mediated by health status, income, and insurance disparities. Public health implications. In Medicare, low-income beneficiaries, especially low-income African Americans with poor health status, should be protected from the unintended financial consequences of cost-reduction strategies.

Factors affecting general practitioner charges and Medicare bulk-billing: results of a survey of Australians.

OBJECTIVE: To identify factors affecting bulk-billing by general practitioners in Australia. DESIGN, PARTICIPANTS AND SETTING: A community-based survey was administered to Australians aged 16 years or older in July 2013 via an online panel. Survey questions focused on patient characteristics, visit characteristics, practice characteristics. MAIN OUTCOME MEASURES: Factors associated with GP bulk-billing. RESULTS: 2477 respondents completed the survey, of whom 2064 (83.33%) reported that the practice that they went to for their most recent GP visit bulk billed some or all patients. Overall, 1763 respondents (71.17%) reported that their most recent GP visit was bulk billed. Taking into account the duration of visits and the corresponding Medicare Benefits Schedule rebate, the mean out-of-pocket cost for those who were not bulk billed was $34.09. RESULTS of a multivariate logistic regression analysis suggest that the odds of being bulk billed was negatively associated with larger practice size, respondents having had an appointment for their visit, higher household income and inner or outer regional area of residence. It was positively associated with the presence of a chronic disease, being a concession card holder and having private health insurance. There was no association between bulk-billing and duration of GP visit, age or sex. CONCLUSIONS: Our results indicate that there are associations between patient characteristics and bulk-billing, and between general practice characteristics and bulk-billing. This suggests that caution is needed when considering changes to GP fees and Medicare rebates because of the many possible paths by which patients' access to services could be affected. Our results do not support the view that bulk-billing is associated with shorter consultation times.

Structured physician order entry for trauma CT: value in improving clinical information transfer and billing efficiency.

OBJECTIVE: The purpose of this study was to measure the effects of use of a structured physician order entry system for trauma CT on the communication of clinical information and on coding practices and reimbursement efficiency. MATERIALS AND METHODS: This study was conducted between April 1, 2011, and January 14, 2013, at a level I trauma center with 59,000 annual emergency department visits. On March 29, 2012, a structured order entry system was implemented for head through pelvis trauma CT, so-called pan-scan CT. This study compared the following factors before and after implementation: communication of clinical signs and symptoms and mechanism of injury, primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code category, success of reimbursement, and time required for successful reimbursement for the examination. Chi-square statistics were used to compare all categoric variables before and after the intervention, and the Wilcoxon rank sum test was used to compare billing cycle times. RESULTS: A total of 457 patients underwent pan-scan CT in 2734 distinct examinations. After the intervention, there was a 62% absolute increase in requisitions containing clinical signs or symptoms (from 0.4% to 63%, p<0.0001) and a 99% absolute increase in requisitions providing mechanism of injury (from 0.4% to 99%, p<0.0001). There was a 19% absolute increase in primary ICD-9-CM codes representing clinical signs or symptoms (from 2.9% to 21.8%, p<0.0001), and a 7% absolute increase in reimbursement success for examinations submitted to insurance carriers (from 83.0% to 89.7%, p<0.0001). For reimbursed studies, there was a 14.7-day reduction in mean billing cycle time (from 68.4 days to 53.7 days, p=0.008). CONCLUSION: Implementation of structured physician order entry for trauma CT was associated with significant improvement in the communication of clinical history to radiologists. The improvement was also associated with changes in coding practices, greater billing efficiency, and an increase in reimbursement success.

Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?

BACKGROUND: Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases. OBJECTIVE: To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA. DESIGN: Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010. PARTICIPANTS: Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010. MAIN MEASURES: Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible. KEY RESULTS: Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1-5 scale, in which 5 is "always" inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was "so they will reconsider staying in the hospital" (84.8% residents, 66.7% attendings, p = 0.008) CONCLUSIONS: Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Gender differences in financial hardships of medical debt.

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003-04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=-0.15, p<.05), using savings (b=-0.23, p<.005), or having any financial hardships associated with medical debt (b=-0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Ways to maximize effective collections.

Medical practices across the country face a variety of collection challenges, especially when considering the condition of today's economy. It is now more important than ever for a practice to establish proactive collection procedures and learn the keys to minimizing collection problems. This starts with educating patients about your payment terms prior to appointments and educating your staff to be aware of early warning signs when an account could become a problem. Taking steps that lead to quick resolution, while retaining patients, is a vital component to increased cash flow and fewer aging accounts in receivables. Careful review of your practice's policies on billing and collections can lead to a greater knowledge on how healthy the practice really is. This article provides key strategies that will help streamline your billing and collections process and recover money owed to you while maintaining those ever so important patient relationships.

Validity of autism diagnoses using administrative health data.

It is necessary to monitor autism prevalence in order to plan education support and health services for affected children. This study was conducted to assess the accuracy of administrative health databases for autism diagnoses. Three administrative health databases from the province of Nova Scotia were used to identify diagnoses of autism spectrum disorders (ASD): the Hospital Discharge Abstract Database, the Medical Services Insurance Physician Billings Database and the Mental Health Outpatient Information System database. Seven algorithms were derived from combinations of requirements for single or multiple ASD claims from one or more of the three administrative databases. Diagnoses made by the Autism Team of the IWK Health Centre, using state-of-the-art autism diagnostic schedules, were compared with each algorithm, and the sensitivity, specificity and C-statistic (i.e. a measure of the discrimination ability of the model) were calculated. The algorithm with the best test characteristics was based on one ASD code in any of the three databases (sensitivity=69.3%). Sensitivity based on an ASD code in either the hospital or the physician billing databases was 62.5%. Administrative health databases are potentially a cost efficient source for conducting autism surveillance, especially when compared to methods involving the collection of new data. However, additional data sources are needed to improve the sensitivity and accuracy of identifying autism in Canada.

Professional charges not reimbursed to dentists in the U.S.: evidence from Medical Expenditure Panel Survey, 1996.

OBJECTIVES: This cross-sectional study examined professional charges not paid to dentists. METHODS: This analysis used logistic regression in SUDAAN examining the 1996 MEPS data from 12,931 adults. RESULTS: Among people incurring dental care charges, 13.6% had more than $50 of unpaid charge (UC). The percapita UC was $53.30. Total UC was higher for highest income group [45.4% of total] compared to lowest income group [26.0%]. The percapita UC of $76.70 for low income group was significantly greater than for high income group ($47.80, P < 0.01). More Medicaid recipients (52% vs. non-recipients: 12%) incurred at least $50 in UC (P < 0.01). Adjusted odds of incurring UC were greater for those employed (OR = 1.3, 95% CI: 1.0-1.7), and for those with private insurance (OR: 1.5, CI: 1.3-1.9). Number of dental procedure types modified the association between Medicaid recipient and UC (OR = 13.6 for Medicaid recipients undergoing multiple procedure types; OR: 2.3 for Medicaid non-recipients with multiple procedure types; OR: 1.9 for Medicaid recipients receiving single dental procedure. CONCLUSIONS: Having private insurance, being unemployed and being Medicaid insured undergoing multiple procedure were strongest predictors of UC.

Childhood asthma surveillance using administrative data: consistency between medical billing and hospital discharge diagnoses.

BACKGROUND: The absence of ongoing surveillance for childhood asthma in Montreal, Quebec, prompted the present investigation to assess the validity and practicality of administrative databases as a foundation for surveillance. OBJECTIVE: To explore the consistency between cases of asthma identified through physician billings compared with hospital discharge summaries. METHODS: Rates of service use for asthma in 1998 among Montreal children aged one, four and eight years were estimated. Correspondence between the two databases (physician billing claims versus medical billing claims) were explored during three different time periods: the first day of hospitalization, during the entire hospital stay, and during the hospital stay plus a one-day margin before admission and after discharge ('hospital stay +/- 1 day'). RESULTS: During 1998, 7.6% of Montreal children consulted a physician for asthma at least once and 0.6% were hospitalized with a principal diagnosis of asthma. There were no contemporaneous physician billings for asthma 'in hospital' during hospital stay +/- 1 day for 22% of hospitalizations in which asthma was the primary diagnosis recorded at discharge. Conversely, among children with a physician billing for asthma 'in hospital', 66% were found to have a contemporaneous in-hospital record of a stay for 'asthma'. CONCLUSIONS: Both databases of hospital and medical billing claims are useful for estimating rates of hospitalization for asthma in children. The potential for diagnostic imprecision is of concern, especially if capturing the exact number of uses is more important than establishing patterns of use.

From bottom to top: how one provider retooled its collections.

In its effort to increase point-of-service collections and improve the overall revenue cycle, Sutter Health took steps to: Measure performance using a handful of specific, primary benchmarks. Empower PFS staff to assume responsibility for every individual account they handle. Ensure each registration is analyzed using a rules engine to identify problems before patients leave the registration desk. Ensure PFS staff receive appropriate comprehensive training to excel under the new system.

Using billing data to describe patterns in asthma-related emergency department visits in children.

OBJECTIVES: To describe the development and evaluation of a pilot emergency department (ED)-based asthma surveillance system for childhood asthma visits based on billing data and to illustrate how the data can be used to document trends and patterns in ED visits for asthma in children. METHODS: During 2001 and 2002, aggregate reports based on ED billing data from 3 hospitals in western Michigan were obtained from a single physician billing company. Data were tabulated and graphed to show trends in the monthly number of ED visits for asthma in children. Comparisons were made by age, gender, and site. We evaluated the system by using established guidelines. RESULTS: The data illustrated strong seasonal trends, as well as marked differences in ED use according to age and gender. The total numbers of asthma ED visits were remarkably similar between the 2 years evaluated; however, the timing and duration of the seasonal peaks differed. Our evaluation of the system found that it met many of the characteristics that define successful surveillance systems, including simplicity, flexibility, acceptability, sensitivity and positive predictive value, timeliness, and stability. However, the surveillance system's representativeness was limited by the inability to calculate valid population-based ED-visit rates. Despite this limitation, the data provided useful information by documenting the burden and demographic profile of children who use the ED for asthma care and in identifying seasonal and time-related trends. CONCLUSIONS: We were able to successfully implement a pilot ED-based surveillance system for childhood asthma visits by using billing data. This system promotes the understanding of the burden of asthma among children visiting the ED. The development of an ED-based surveillance system for childhood asthma visits using billing data is recommended, particularly when there is a desire to understand the characteristics of children with asthma who use the ED and/or a need to understand the impact of local asthma quality-improvement programs.

Charges for hospital admissions attributable to health disparities for African-American patients, 1998-2002.

OBJECTIVE: Racial disparities exist across most major disease categories, which result in a disproportionately large number of hospital admissions for many conditions. Estimates for the financial impact of the racial admission differences for the State of South Carolina are assessed. METHODS: South Carolina hospital discharge data for 1998-2002 was used for the analysis. The database includes all-payer billing data for inpatient hospital admissions as received on the UB-92 billing file for the covered episode. Charges were inflation adjusted to 2002 constant dollars. RESULTS: For 1998-2002, there were an estimated dollar 1.6 billion in total charges for hospital admissions in South Carolina that were attributed to higher age-adjusted admission rates for African-American patients. In addition, African Americans had consistently higher hospital admission rates for disease categories that are often associated with a failure to obtain ambulatory and preventive care. CONCLUSION: This simple analysis reveals that age-adjusted hospital admission rates for African Americans in South Carolina are higher than for Caucasians, and the gap appears to be widening over time. Given the magnitude of the financial implication, interventions with even a small impact on the conditions underlying the racial disparities in hospital admissions are likely to be cost effective.