Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention.

BACKGROUND: Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014. METHODS: We analyzed all emergency department (ED) visits from 2009 to 2014 with diagnosis codes for violent injury in the Nationwide Emergency Department Sample (NEDS). We used sample weights to estimate total charges with adjusted generalized linear models to estimate charges for the 15% of ED visits with missing charge data. We then calculated the share attributable by payer and determined the difference in proportion by payer from 2013 to 2014. RESULTS: Between 2009 and 2013, the uninsured accounted for 28.2-31.3% of annual charges for the acute care of violent injury, while Medicaid was responsible for a similar amount (29.0-31.0%). In 2014, there were $10.7 billion in total charges for violent injury. Medicaid assumed the greatest share, 39.8% (95% CI: 38.0-41.5%, $3.5-5.1 billion), while the uninsured accounted for 23.6% (95% CI: 22.2-24.9%, $2.0-3.0 billion), and Medicare accounted for 7.8% (95% CI: 7.7-8.0%, $0.7-1.0 billion). CONCLUSION: After Medicaid expansion, taxpayers are now accountable for nearly half of the $10.7 billion in annual charges for the acute care of violent injury in the U.S. These findings highlight the benefit to state Medicaid programs of preventing interpersonal violence.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

BACKGROUND: Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. METHODS: We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. RESULTS: An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. CONCLUSION: Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. LEVEL OF EVIDENCE: Epidemiological study, level III.

[Psychiatry and psychiatric patients : A study of the adherence after psychiatric inpatient treatment at the department of psychiatry and psychotherapy at the Clinicum Klagenfurt am Wörthersee.] / Die Psychiatrie und ihre PatientInnen : Eine Studie zur Adhärenz nach Entlassung aus der Abteilung für Psychiatrie und Psychotherapie am Klinikum Klagenfurt am Wörthersee.

BACKGROUND: Based on the data of an analysis of costs of psychopharmacological treatment by the Austrian Rechnungshof in 2011, which also revealed remarkable differences between Salzburg and Carinthia (federal states of Austria), a panel of experts discussed the potential causes. A consequence was the following prospective study, which took place at the department of psychiatry and psychotherapy in Klagenfurt/Carinthia. METHODS: The aim in this mirror design study was to analize the data of psychopharmacologic treatment, epidemiological data of the treated patients (N = 230) and utilization of healthcare ressources such as contacts to psychiatrists or practicioners after discharge. RESULTS: We could show a high adherence concerning the redeem of the prescriptions, a low proportion of generics, and a very low rate of contacts to psychiatrists contrasting contacts to practitioners. CONCLUSIONS: Beneath that in the sense of descriptive epidemiology the data help to characterize adherence behavior after discharge and details of in- and outdoor treatment.

HINN, IM , and MOON: Alphabet Soup of Forms Can Be Confusing.

The Centers for Medicare & Medicaid Services requires hospitals to give patients an array of documents to explain their rights, their status, and any financial obligations they may incur ­ and it's usually up to case managers to see that the hospital complies. •The Medicare Outpatient Observation Notice (MOON) is the latest requirement, but the Important Message (IM) from Medicare also is required under the Medicare Conditions of Participation. In order to bill patients for services that are incurred but not covered, hospitals also must give patients a Hospital Issued Notice of Noncoverage (HINN). •If the documents are delivered at the proper time, they could affect the hospital's reimbursement, increase the risk of audit, and affect patients' understanding of their rights and responsibilities. •The entire treatment team should be aware of the documents and intentions. Education on delivering these documents should be part of case management orientation and regular education. •Hospitals should develop a process for delivering HINNs if the need arises. Before that happens, case managers should communicate frequently with the patient and family about the next level of care. •Patients may demand that their status be changed from observation to inpatient, but they can't be admitted unless they meet inpatient criteria.

Family-Provided Health Care for Children With Special Health Care Needs.

BACKGROUND AND OBJECTIVES: Many children with special health care needs (CSHCN) receive health care at home from family members, but the extent of this care is poorly quantified. This study's goals were to create a profile of CSHCN who receive family-provided health care and to quantify the extent of such care. METHODS: We analyzed data from the 2009-2010 National Survey of Children with Special Health Care Needs, a nationally representative sample of 40 242 parents/guardians of CSHCN. Outcomes included sociodemographic characteristics of CSHCN and their households, time spent by family members providing health care at home to CSHCN, and the total economic cost of such care. Caregiving hours were assessed at (1) the cost of hiring an alternative caregiver (the "replacement cost" approach), and (2) caregiver wages (the "foregone earnings" approach). RESULTS: Approximately 5.6 million US CSHCN received 1.5 billion hours annually of family-provided health care. Replacement with a home health aide would have cost an estimated $35.7 billion or $6400 per child per year in 2015 dollars ($11.6 billion or $2100 per child per year at minimum wage). The associated foregone earnings were $17.6 billion or $3200 per child per year. CSHCN most likely to receive the greatest amount of family-provided health care at home were ages 0 to 5 years, were Hispanic, lived below the federal poverty level, had no parents/guardians who had finished high school, had both public and private insurance, and had severe conditions/problems. CONCLUSIONS: US families provide a significant quantity of health care at home to CSHCN, representing a substantial economic cost.

Reducing Anesthesia and Health Care Cost Through Utilization of Child Life Specialists in Pediatric Radiation Oncology.

PURPOSE: To analyze the effectiveness of a certified child life specialist (CCLS) in reducing the frequency of daily anesthesia at our institution, and to quantify the potential health care payer cost savings of CCLS utilization in the United States. METHODS AND MATERIALS: From 2006 to 2014, 738 children (aged ≤21 years) were treated with radiation therapy at our institution. We retrospectively analyzed the frequency of daily anesthesia before and after hiring a CCLS in 2011 after excluding patients aged 0 to 2 and >12 years. In the analyzed cohort of 425 patients the median age was 7.6 years (range, 3-12.9 years). For the pre-CCLS period the overall median age was 7.5 years; for the post-CCLS period the median age was 7.7 years. An average 6-week course of pediatric anesthesia for radiation therapy costs $50,000 in charges to the payer. The average annual cost to employ one CCLS is approximately $50,000. RESULTS: Before employing a CCLS, 69 of 121 children (57%) aged 3 to 12 years required daily anesthesia, including 33 of 53 children (62.3%) aged 5 to 8 years. After employing a CCLS, 124 of 304 children (40.8%) aged 3 to 12 years required daily anesthesia, including only 34 of 118 children (28.8%) aged 5 to 8 years (P<.0001). With a >16% absolute reduction in anesthesia use after employment of a CCLS, the health care payer cost savings was approaching $50,000 per 6 children aged 3 to 12 years treated annually with radiation therapy in our institution. This reduction resulted in a total of only 6 children aged 3 to 12 years required anesthesia to be treated per year at our center to achieve nearly break-even cost savings to the health care payer if the payer were to subsidize the employment expense of a CCLS. Overall, the CCLS intervention can provide an average annualized health care payer cost savings of "$[(anesthesia cost to payer during radiation therapy course/6) - (CCLS expense to payer/N)]" per child (N) treated with radiation therapy, where N equals the number of children aged 3 to 12 years treated in 1 year. This formula assumes that the payer subsidizes the cost for the employment of a CCLS, although our institution absorbed this expense for this data cohort. The predicted annualized health care system cost savings from reducing the frequency of anesthesia with radiation therapy when treating 100 children aged 3 to 12 years per year could exceed $775,000. CONCLUSIONS: These data suggest that a CCLS significantly reduces the frequency of daily anesthesia for children treated with radiation therapy. Health care system payers may achieve significant cost savings by financially supporting the employment of a CCLS in high-volume pediatric radiation therapy centers.

[Incidence and Costs of 1:1 Care in Psychiatric Hospitals in Germany - A Descriptive Analysis Based on the VIPP Project Data Set]. / Häufigkeit und Kosten der 1:1-Betreuung in der Erwachsenenpsychiatrie in Deutschland - Eine deskriptive Analyse anhand des VIPP-Datensatzes.

OBJECTIVE: 1:1 care is applied for patients requiring close psychiatric monitoring and care like patients with acute suicidality. The article describes the frequency of 1:1 care across different diagnoses and age groups in German psychiatric hospitals. METHODS: The analysis was based on the VIPP Project from the years 2011 and 2012. A total of 47 hospitals with more than 120,000 cases were included. Object of the analysis was the OPS code 9-640.0 1:1 care. The evaluation was performed on case level. RESULTS: Data of 47 hospitals were included. Of the 121,454 cases evaluated in 2011 3.8 % documented a 1:1 care within the meaning of OPS 9-640.0 additional code. Of the 66 245 male cases a 1:1 care was documented in 3.5 % and the 55 207 female cases was 4.1 %. Compared to 2011, the proportion of 1:1 care in 2012 rose to 4.8 %. CONCLUSION: The results show that 1:1 care is frequently applied in German psychiatric hospitals. The Data of the VIPP project have proven to be a useful tool to gain information on the frequency of cost-intensive interventions in German psychiatric hospitals. Further analyses should create the possibility of evaluation at the level of the individual codes.

[FIMA--questionnaire for health-related resource use in an elderly population: development and pilot study]. / FIMA--Fragebogen zur Erhebung von Gesundheitsleistungen im Alter: Entwicklung und Pilotstudie.

AIM: Due to demographic trends towards an ageing population resource use of health care will increase. By collecting health-related costs via questionnaires, the impact of socio-economic variables and other medical factors can be examined. In addition, only patient reported resource use accounts for out-of-pocket payments. Thus, it is necessary to develop an appropriate tool to collect the health-related resource use in an elderly population. METHODS: The development of the FIMA (questionnaire for the use of medical and non-medical services in old age) was carried out in 6 steps. These included the determination of necessary questionnaire contents based on a literature review and the wording and layout were defined. Finally the questionnaire was tested in a pilot study and was modified. RESULTS: All direct medical and non-medical resource use excluding transportation and time costs were recorded. Productivity losses were not included. The recall time frames differed according to resource categories (7 days, 3 months, 12 months). For the pilot study, 63 questionnaires were analysed. The response rate was 69%. The questionnaire took an average of 21 min to complete. Three quarters of respondents completed the questionnaire without help and 90% rated the difficulty as easy or even very simple. There was good agreement between self-reported health-related quality of life and the resource use of nursing and domestic help (phi coefficient values between 0.52 and 0.58). CONCLUSION: The FIMA is a generic questionnaire which collects the health-related resource use within the older population groups.

[Calculation of standardised unit costs from a societal perspective for health economic evaluation]. / Ermittlung standardisierter Bewertungssätze aus gesellschaftlicher Perspektive für die gesundheitsökonomische Evaluation.

PURPOSE: Due to demographic aging, economic evaluation of health care technologies for the elderly becomes more important. A standardised questionnaire to measure the health-related resource utilisation has been designed. The monetary valuation of the resource use documented by the questionnaire is a central step towards the determination of the corresponding costs. The aim of this paper is to provide unit costs for the resources in the questionnaire from a societal perspective. METHODS: The unit costs are calculated pragmatically based on regularly published sources. Thus, an easy update is possible. RESULTS: This paper presents the calculated unit costs for outpatient medical care, inpatient care, informal and formal nursing care and pharmaceuticals from a societal perspective. CONCLUSION: The calculated unit costs can serve as a reference case in health economic evaluations and hence help to increase their comparability.

Wishard Volunteer Advocates Program: an intervention for at-risk, incapacitated, unbefriended adults.

Unbefriended, incapacitated individuals who lack surrogates to make medical decisions present a complex problem to the healthcare providers who treat them. Adults without surrogates are among the most vulnerable in the community and are often alone and estranged from family, neglected and abused, and at risk of receiving inappropriate medical treatment. This article describes the program model and outcomes for the first 2 years of the Wishard Volunteer Advocates Program (WVAP), a guardianship program using trained, supervised volunteers as surrogates for unbefriended, incapacitated individuals. Of the 50 individuals enrolled during the study period, 20 were female, and 39 were Caucasian and 11 African American. Their average age was 67. Nineteen were insured with Medicare as primary and Medicaid as supplementary insurance. Ninety-eight percent had four or more comorbid conditions at the time of the index hospitalization. Before program referral, many lived alone in unsafe conditions. Adult Protective Services was involved in almost half of the cases at the time of the index hospitalization. Approximately half of the participants required some type of property management. Healthcare usage data demonstrated that most were not receiving medical care before WVAP enrollment; the data indicated a decrease in emergency department visits and hospitalization after WVAP enrollment. The WVAP completed Medicaid applications for 12 participants, resulting in $297,481.62 in reimbursement for the index hospitalization and a payer source for subsequent hospitalization and long-term care. The volunteer advocate model provides an efficient and quality mechanism for providing unbefriended individuals with surrogates.

[Comparison of management of ambulatory emergency patients in the family practice and the hospital emergency center]. / Vergleich der Betreuung ambulanter Notfallpatienten in der hausärztlichen Praxis und dem Zentrumsspital.

The increase in health care cost is broadly discussed in the public, either in the hospital or ambulatory setting. With the present study we compared the invoice amount generated by a first doctor's advice in the general practitioner to the one in the emergency room. In addition, we compared the diagnostic procedures used in the general practice to the one in the hospital, and whether the choice of diagnostic procedures would substantially influence the invoice amount. The invoice amount in the hospital setting was on average CHF 197.-, i. e. 134%, higher compared to the general practice. The difference in the invoice amount was largely explained by more diagnostic procedures in the hospital. Moreover, part of the higher invoice amount was generated by the extensive physical examination by doctors in the hospital.

L'augmentation des coûts en soins médicaux, en particulier en médecine ambulatoire, est largement discutée ces derniers temps. Au moyen d'une étude comparant les premières consultations au Service d'urgence interdisciplinaire (INO) de l'hôpital cantonal de Winterthur (KSW), respectivement du Service d'urgence des généralistes, nous avons éxaminé quels montants sont facturés lors d'une première consultation ambulatoire. En outre, nous avons comparé le traitement effectué par les généralistes à celui de l'hôpital et nous avons analysé si le choix du traitement influence le montant de la facture. Nos résultats ont démontré que le coût moyen du traitement par patient à l'hôpital était de CHF 197.­ (134%) supérieur à celui des généralistes. Cette différence des coûts a pu être expliquée en grande partie qu'au KSW plus de mesures diagnostiques furent prises. Les dépenses accrues ont été provoquées non seulement par les examens techniques, mais aussi par l'importance de la participation des médecins aux soins à en milieu hospitalier.

The value of all-payer claims databases to states.

All-payer claims databases are being developed in states across the nation to fill gaps in information about the health care system. The value of such databases is becoming more apparent as these databases mature and are used more frequently to help states better understand their health care utilization and costs.

Condition Code 44 or Condition Code W2?

When hospitals determine after discharge that a patient did not meet inpatient criteria, they can file a provider liable claim using Condition Code W2 and be reimbursed for all services as if the patient were an outpatient, according to Deborah Hale, CCS, CCDS. The claims must be filed within 12 months after discharge. The medical record must be reviewed by the physician advisor and the utilization review committee before the claim is submitted. It is still advantageous to get the patient status right up front.

Medicaid 'welcome-mat' effect of Affordable Care Act implementation could be substantial.

The Affordable Care Act will have important impacts on state Medicaid programs, likely increasing participation among populations that are currently eligible but not enrolled. The size of this "welcome-mat" effect is of concern for two reasons. First, the eligible but uninsured constitute a substantial share of the uninsured population in some states. Second, the newly eligible population will affect states' Medicaid caseloads and budgets. Using the Massachusetts 2006 health reforms as a case study and controlling for other factors, we found that among low-income parents who were previously eligible for Medicaid in Massachusetts, Medicaid enrollment increased by 16.3 percentage points, and Medicaid participation by those without private coverage increased by 19.4 percentage points, in comparison to a group of control states. In many states the potential size of the welcome-mat effect could be even larger than what we observed in Massachusetts. Our analysis has potentially important implications for other states attempting to predict the impact of this effect on their budgets.

[Costs of delivering allogenic blood in hospitals]. / Kosten der Verabreichung von Blutkonserven im Krankenhaus.

INTRODUCTION: In clinical practice there are medical and economic reasons against the thoughtless use of packed red blood cells (rbc). Therefore, in searching for alternatives (therapy of anemia) the total costs of allogeneic blood transfusions must be considered. Using a practical example this article depicts the actual costs and possible alternatives from the point of view of a hospital in Germany. METHOD: To determine the total costs of allogeneic blood transfusions the actual resource consumption associated with blood transfusions was collated and analyzed at the St. Marien-Hospital in Vechta. RESULTS: The authors were able to show that the actual procurement costs (average. 97 EUR) represent only 55 % of the total costs of 176 EUR. The additional expenses are allocated to personnel (78 %) and materials (22 %). Alternatives, such as i.v. iron substitution or stimulation of erythropoesis might be the more economical solution especially if only purchase prices are compared and the total costs of allogeneic blood transfusions are not considered. DISCUSSION: Analyzing a single hospital limits generalization of the results; however, in the international context the results can be recognized as plausible. So far there have been no comprehensive studies on the true costs of blood preparations, therefore, this article represents a first starting point for closing this gap by conducting additional studies.

The dynamics of medical care use in the British household panel survey.

We explore whether medical care use is persistent over a long panel using 18 waves of the British Household Panel Survey. Of particular interest is high medical care use because a few high users account for a disproportionate amount of use while many individuals use no medical care in a given year. If health is a primary driver of medical care demand, and we control for health, then past medical care use should be uninformative for future use. However, we find that conditional on health, other covariates and unobservable heterogeneity, medical care use remains significantly persistent. "No use" and "high use" are more strongly persistent, and persistence is generally stronger for women, those in poor health, and at older ages. We find that unobservable heterogeneity explains between 10% and 25% of the variation in medical care use. This heterogeneity is significantly correlated with both medical care use and health over our long panel. These findings have implications for the econometric modeling of medical care demand and suggest that policies aimed to reduce aggregate medical care spending by improving health, particularly the health of seniors, may be less effective than projected using static models.

Patterns and costs of health care use of children with medical complexity.

BACKGROUND AND OBJECTIVE: Health care use of children with medical complexity (CMC), such as those with neurologic impairment or other complex chronic conditions (CCCs) and those with technology assistance (TA), is not well understood. The objective of the study was to evaluate health care utilization and costs in a population-based sample of CMC in Ontario, Canada. METHODS: Hospital discharge data from 2005 through 2007 identified CMC. Complete health system use and costs were analyzed over the subsequent 2-year period. RESULTS: The study identified 15 771 hospitalized CMC (0.67% of children in Ontario); 10 340 (65.6%) had single-organ CCC, 1063 (6.7%) multiorgan CCC, 4368 (27.6%) neurologic impairment, and 1863 (11.8%) had TA. CMC saw a median of 13 outpatient physicians and 6 distinct subspecialists. Thirty-six percent received home care services. Thirty-day readmission varied from 12.6% (single CCC without TA) to 23.7% (multiple CCC with TA). CMC accounted for almost one-third of child health spending. Rehospitalization accounted for the largest proportion of subsequent costs (27.2%), followed by home care (11.3%) and physician services (6.0%). Home care costs were a much larger proportion of costs in children with TA. Children with multiple CCC with TA had costs 3.5 times higher than children with a single CCC without TA. CONCLUSIONS: Although a small proportion of the population, CMC account for a substantial proportion of health care costs. CMC make multiple transitions across providers and care settings and CMC with TA have higher costs and home care use. Initiatives to improve their health outcomes and decrease costs need to focus on the entire continuum of care.