RESUMO
Las demandas por malpraxis en odontología se han incrementado en los últimos años, siendo la implantología una de las especialidades más litigadas. Estas demandas en su mayoría se han caracterizado por tener un carácter multifactorial, con errores reportados en cualquiera de sus fases diagnósticas, terapéuticas o de mantenimiento. El propósito de esta revisión fue establecer la etapa del tratamiento implantológico en la que más se realizaron demandas por malpraxis, estableciendo una categorización de los errores detectados y de los daños asociados a cada una de las fases que incluye el tratamiento de rehabilitación mediante implantes dentales. Se realizó una revisión con búsqueda sistemática de los últimos 10 años en las bases Pubmed, Scopus, Web of Science, SciELO, complementada con una búsqueda manual en revistas especializadas y en Google Scholar de artículos a partir de términos clave en idiomas español inglés y portugués. Se identificaron solo 3 artículos que cumplieron los criterios de selección, lo que afirma el concepto de escasa atención hacia esta eventualidad. Las demandas identificadas en esos reportes fueron analizadas sobre cuatro tipos de riesgo en implantología según la etapa del tratamiento en la que aparecen. La etapa quirúrgica fue identificada como la de mayor potencial de riesgo de originar eventos adversos y demandas asociadas. Se sugiere profundizar en los aspectos medicolegales propios y genéricos de la especialidad, como así también en el desarrollo de estrategias que prevengan sus eventos adversos y la judicialización asociada.
Dental malpractice claims have increased in recent years, and implantology is one of the most litigated specialties. Most of these claims have been characterized by having a multifactorial nature, with errors reported in any of their diagnostic, therapeutic or maintenance phases. The purpose of this review was to establish the stage of implant treatment in which the most malpractice claims were made, establishing a categorization of the errors detected and damages associated with each of the phases that includes rehabilitation treatment using dental implants. A review was carried out with a systematic search of the last 10 years in Pubmed, Scopus, Web of Science and SciELO databases, complemented with a manual search in specialized journals and in Google Academic, of articles from key words in Spanish, English and Portuguese languages. Only 3 articles were identified that met the selection criteria, which affirms the concept of scant attention given to this eventuality. The claims identified in these reports were analyzed on four types of risk in implantology according to the stage of treatment in which they appear. The surgical stage was identified as the one with the highest risk potential of causing adverse events and associated demands. It is suggested to deepen the specific and generic medico-legal aspects of the specialty, as well as in the development of strategies to prevent adverse events and the associated litigation.
Assuntos
Humanos , Implantes Dentários/efeitos adversos , Imperícia/legislação & jurisprudência , Revisão da Utilização de Seguros/organização & administração , Revisão da Utilização de Seguros/estatística & dados numéricos , Responsabilidade Legal , Risco à Saúde Humana , Imperícia/economiaRESUMO
The Main Association of Austrian Social Security Institutions collects pseudonymized claims data from Austrian social security institutions and information about hospital stays in a database for research purposes. For new studies the same data are repeatedly reprocessed and it is difficult to compare different study results even though the data is already preprocessed and prepared in a proprietary data model. Based on a study on adverse drug events in relation to inappropriate medication in geriatric patients the suitability of the Observational Medical Outcomes Partnership (OMOP) common data model (CDM) is analyzed and data is transformed into the OMOP CDM. 1,023 (99.7%) of drug codes and 3,812 (99.2%) of diagnoses codes coincide with the OMOP vocabularies. The biggest obstacles are missing mappings for the Local Vocabularies like the Austrian pharmaceutical registration numbers and the Socio-Economic Index to the OMOP vocabularies. OMOP CDM is a promising approach for the standardization of Austrian claims data. In the long run, the benefits of standardization and reproducibility of research should outweigh this initial drawback.
Assuntos
Bases de Dados Factuais/normas , Revisão da Utilização de Seguros/organização & administração , Idoso , Idoso de 80 Anos ou mais , Áustria/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Estudos de Viabilidade , Geriatria , Humanos , Revisão da Utilização de Seguros/normas , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Reprodutibilidade dos Testes , Fatores SocioeconômicosAssuntos
Big Data , Bases de Dados Factuais/normas , Interações Medicamentosas , Sistemas de Informação/organização & administração , Vigilância de Produtos Comercializados , Biologia Computacional , Coleta de Dados , Registros Eletrônicos de Saúde/organização & administração , Humanos , Revisão da Utilização de Seguros/organização & administraçãoRESUMO
OBJECTIVES: To describe how all-payer claims databases (APCDs) can be used for multistate analysis, evaluating the feasibility of overcoming the common barrier of a lack of standardization across data sets to produce comparable cost and quality results for 4 states. This study is part of a larger project to better understand the cost and quality of healthcare services across delivery organizations. STUDY DESIGN: Descriptive account of the process followed to produce healthcare quality and cost measures across and within 4 regional APCDs. METHODS: Partners from Colorado, Massachusetts, Oregon, and Utah standardized the calculations for a set of cost and quality measures using 2014 commercial claims data collected in each state. This work required a detailed understanding of the data sets, collaborative relationships with each other and local partners, and broad standardization. Partners standardized rules for including payers, data set elements, measure specifications, SAS code, and adjustments for population differences in age and gender. RESULTS: This study resulted in the development of a Uniform Data Structure file format that can be scaled across populations, measures, and research dimensions to provide a consistent method to produce comparable findings. CONCLUSIONS: This study demonstrates the feasibility of using state-based claims data sets and standardized processes to develop comparable healthcare performance measures that inform state, regional, and organizational healthcare policy.
Assuntos
Custos e Análise de Custo/estatística & dados numéricos , Formulário de Reclamação de Seguro/estatística & dados numéricos , Revisão da Utilização de Seguros/organização & administração , Reembolso de Seguro de Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Colorado , Bases de Dados como Assunto , Feminino , Humanos , Disseminação de Informação , Formulário de Reclamação de Seguro/economia , Revisão da Utilização de Seguros/economia , Seguro Saúde/economia , Reembolso de Seguro de Saúde/economia , Masculino , Massachusetts , Oregon , UtahRESUMO
Medical malpractice claims can be analysed to gain insights aimed at improving quality of care. However, using medical malpractice claims in medical research raises epistemological and methodological concerns related to certain features of the litigation process. Medical research should therefore approach medical malpractice claims with caution. Taking one recent study as a an example, this article insists on three areas of concern: (a) the quantity of legal materials available for analysis; (b) the content of the legal materials available for analysis; and (c) the ways in which the content of the legal materials should be analysed and the types of inferences that it can support. The article concludes with general recommendations for future medical research that would incorporate medical malpractice claims. These recommendations centre around recognizing the qualitative dimension of legal reasoning.
Assuntos
Pesquisa Biomédica , Revisão da Utilização de Seguros/organização & administração , Imperícia , Erros Médicos , Qualidade da Assistência à Saúde/organização & administração , Pesquisa Biomédica/ética , Pesquisa Biomédica/métodos , Pesquisa Biomédica/normas , Causalidade , Prova Pericial/métodos , Prova Pericial/normas , Humanos , Jurisprudência , Conhecimento , Responsabilidade Legal , Imperícia/legislação & jurisprudência , Imperícia/estatística & dados numéricos , Erros Médicos/legislação & jurisprudência , Erros Médicos/prevenção & controle , Erros Médicos/estatística & dados numéricos , Projetos de PesquisaRESUMO
PURPOSE: To study social validity and perceived fairness of a new method for assessing general work ability in a sickness insurance context. Assessments are based on self-reports, combined with examinations by physicians, and, if needed, occupational therapists, physiotherapists and/or psychologists. MATERIALS AND METHODS: Interviews with 36 insurance officials, 10 physicians, and 36 sick-listed persons, which were analysed through a qualitative content analysis. RESULTS: Insurance officials and physicians considered the method useful and that it facilitated benefit decisions. The experiences of persons who had undergone the assessment differed, where the dialog with insurance officials seemed to have had an influence on experiences of the assessment and the decisions it led to. CONCLUSIONS: The perceived fairness and social validity of the assessment depended on how it was carried out; organisational conditions and priorities; communication skills; and decision outcomes. Professionals have an important pedagogical task in explaining the purpose and procedure of the assessment in order for the sick-listed to perceive it as fair rather than square, i.e., too standardised and not considering individual conditions. If the assessment could be used also for rehabilitative purposes, it could possibly be perceived as more acceptable also in cases where it leads to denied benefits. Implications for rehabilitation The perceived fairness of work ability assessments is dependent on procedures for the assessment, communication with the person, and the outcome. What is considered fair differs between assessing professionals and persons being assessed. Professionals may influence the perceptions of fairness through their way of communication. Assessments need to be coupled with rehabilitation measures in order to perceived as relevant and acceptable.
Assuntos
Avaliação da Deficiência , Revisão da Utilização de Seguros/organização & administração , Retorno ao Trabalho , Licença Médica , Avaliação da Capacidade de Trabalho , Adulto , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Validade Social em Pesquisa , SuéciaRESUMO
BACKGROUND: Administrative costs (AC) are a relevant spending category in health care, and several approaches exist on how to define and measure them. Based on available AC studies, this paper aims to provide a map for this multifaceted research topic. METHODS: A scoping review was conducted using the databases MEDLINE, EconLit, and Business Source Premier. Literature was screened focussing on the research question: What is known about the methodology of AC research from scientific publications? RESULTS: Definition concepts mostly rely on national cost documentations. The international cost reporting framework of the Systems of Health Accounts was a critical reference point in six studies. Indications on how to operationalise AC independently from periodical cost reports were suggested by ten publications. In this context, time and full time equivalents are the most common cost measurements. CONCLUSIONS: The results indicate a lack of evidence regarding patients' perceptions of administrative issues in health care. Also, research on administrative impact on working conditions for health care employees beyond hospitals and physicians' offices is underrepresented. A systematic approach to reporting AC studies is needed. Reporting should include the appointment of entities actually empowered to change administrative resource usage. This would help to promote principles of a balanced administration.
Assuntos
Análise Custo-Benefício , Atenção à Saúde/economia , Administração Hospitalar/economia , Humanos , Revisão da Utilização de Seguros/economia , Revisão da Utilização de Seguros/organização & administraçãoRESUMO
Health systems typically lose approximately 3% to 5% of net revenues annually due to insurance claim denials. While most denials can be appealed, the administrative burden of sorting through and appealing them can be time consuming and delays the revenue collection process. This article describes how the Lean Six Sigma methodology was used to improve the revenue cycle by reducing insurance claim denials for a leading pediatric hospital in the United States. The use of this approach is demonstrated through a case example focused on reducing denials by improving the hospital's Emergency Center registration process. Multiple pilot tests were performed to ensure the proposed changes sufficiently addressed the problem of missing/incomplete insurance information. Results indicated that the revised registration form reduced missing/incomplete fields by 67%. As a result, the revised form was implemented, which helped greatly reduce insurance claim denials. In addition to providing an example from which other health systems can learn to successfully implement Lean Six Sigma to enhance the performance of their revenue cycle, this work helped the hospital in which this research was performed improve its patient experience by making it easier for patients to complete their Emergency Center registration form.
Assuntos
Eficiência Organizacional , Revisão da Utilização de Seguros/organização & administração , Melhoria de Qualidade , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Humanos , Revisão da Utilização de Seguros/economia , Seguro Saúde/economia , Seguro Saúde/organização & administração , Projetos Piloto , Melhoria de Qualidade/organização & administração , Estados UnidosRESUMO
Parallel reimbursement regimes, under which providers have some discretion over which payer gets billed for patient treatment, are a common feature of health care markets. In the U.S., the largest such system is under Workers' Compensation (WC), where the treatment workers with injuries that are not definitively tied to a work accident may be billed either under group health insurance plans or under WC. We document that there is significant reclassification of injuries from group health plans into WC, or "claims shifting", when the financial incentives to do so are strongest. In particular, we find that injuries to workers enrolled in capitated group health plans (such as HMOs) see a higher incidence of their claims for soft-tissue injuries (which are hard to classify specifically as work related) under WC than under group health, relative to those in non-capitated plans. Such a pattern is not evident for workers with traumatic injuries. Moreover, we find that such reclassification is more common in states with higher WC fees, once again for soft tissue but not traumatic injuries. Our results imply that a significant shift towards capitated reimbursement, or reimbursement reductions, under GH could lead to a large rise in the cost of WC plans.
Assuntos
Revisão da Utilização de Seguros/organização & administração , Mecanismo de Reembolso/organização & administração , Adolescente , Adulto , Capitação/organização & administração , Feminino , Humanos , Seguro Saúde/organização & administração , Masculino , Pessoa de Meia-Idade , Traumatismos Ocupacionais/classificação , Traumatismos Ocupacionais/economia , Lesões dos Tecidos Moles/classificação , Estados Unidos , Indenização aos Trabalhadores/organização & administração , Ferimentos e Lesões/economia , Adulto JovemRESUMO
Just as radiologic studies allow us to see past the surface to the vulnerable and broken parts of the human body, medical malpractice claims help us see past the surface of medical errors to the deeper vulnerabilities and potentially broken aspects of our healthcare delivery system. And just as the insights we gain through radiologic studies provide focus for a treatment plan for healing, so too can the analysis of malpractice claims provide insights to improve the delivery of safe patient care. We review 1325 coded claims where Radiology was the primary service provider to better understand the problems leading to patient harm, and the opportunities most likely to improve diagnostic care in the future.
Assuntos
Erros de Diagnóstico/estatística & dados numéricos , Revisão da Utilização de Seguros/estatística & dados numéricos , Imperícia/estatística & dados numéricos , Radiologia , Comunicação , Erros de Diagnóstico/economia , Humanos , Revisão da Utilização de Seguros/organização & administração , Responsabilidade Legal , Imperícia/economia , Imperícia/legislação & jurisprudênciaRESUMO
We are revising our rules so that more of our procedures at the hearing and Appeals Council levels of our administrative review process are consistent nationwide. We anticipate that these nationally consistent procedures will enable us to administer our disability programs more efficiently and better serve the public.
Assuntos
Definição da Elegibilidade/legislação & jurisprudência , Definição da Elegibilidade/organização & administração , Revisão da Utilização de Seguros/legislação & jurisprudência , Revisão da Utilização de Seguros/organização & administração , Previdência Social/legislação & jurisprudência , Previdência Social/organização & administração , Avaliação da Deficiência , Humanos , Seguro por Deficiência/legislação & jurisprudência , Seguro por Deficiência/organização & administração , Estados UnidosAssuntos
Avaliação da Deficiência , Prova Pericial/métodos , Revisão da Utilização de Seguros/organização & administração , Doenças Profissionais/diagnóstico , Doenças Profissionais/economia , Local de Trabalho/classificação , Prova Pericial/economia , Alemanha , Humanos , Doenças Profissionais/classificação , Local de Trabalho/economiaAssuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Revisão da Utilização de Seguros/organização & administração , Seguro Saúde/organização & administração , Transtornos Mentais/terapia , Admissão do Paciente/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Rhode Island , Adulto JovemRESUMO
CMS has made changes in the scope of work for the Recovery Auditor program and has proposed a number of other changes to be implemented when new RA contracts are issued. CMS has restricted the number of additional documentation requests, has shortened the "look-back" period for patient status reviews, and announced penalties for RAs with high error rates. The new contracts shorten the time RAs have to complete complex reviews, requires RAs to wait 30 days before referring cases to the Medicare Administrative Contractors, and postpones contingency payments to RAs until after the second level of appeals. The Audit and Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) bill, introduced in the Senate in December, revamps the appeals process, adding an Ombudsman for Medicare Reviews to assist in resolving complaints by hospitals that have appealed and those considering appeals, and establishes an Appeals Medicare Magistrate program with attorneys who will handle appeals of denials for $1,500 or less.
Assuntos
Centers for Medicare and Medicaid Services, U.S. , Revisão da Utilização de Seguros/organização & administração , Política Organizacional , Serviços Contratados , Inovação Organizacional , Estados UnidosRESUMO
The ageing society issue has necessitated the Japanese government conducting health reform. In order to reorganize the health service delivery system, the Ministry of Health, Labour and Welfare (MHLW) has prepared two massive health related data bases; DPC (Diagnosis Procedure Combination) data and NDB (National Receipt Database). The former gathers about 11 million discharged cases from 1,900 acute care hospitals annually. The latter gathers more than 1.7 billion claim data from all medical facilities every year. Using these data bases, we can evaluate the current system and estimate the future health needs of each region. As the backbone of the Japanese health system is a publicly funded private dominant supply system, the existence of useful information concerning health needs is crucial for sound management, especially for the private sector. In this article, the author reveals some examples of the application of these two massive databases for regional health planning and hospital management.
Assuntos
Grupos Diagnósticos Relacionados/organização & administração , Processamento Eletrônico de Dados , Administração Hospitalar , Revisão da Utilização de Seguros/organização & administração , Bases de Dados Factuais , Política de Saúde , Humanos , JapãoRESUMO
In 2013, 22% of the federal budget was spent on Medicare and Medicaid. The Medicare Trust Fund is forecast to be depleted in 2030. More than 12% of Medicare fee-for-service payments in 2014 were made in error. These factors have led Congress to apply more pressure to reduce improper payments. Although hospitals were the initial targets because of their higher reimbursement, recent efforts have shifted to physician billing. Hospitals and health systems continue to acquire physician practices, making them liable for the billing activities of physicians. And for physicians who remain independent, the cost and effort required to respond to audits and denials can be financially devastating, further demonstrating the importance of prevention. This article addresses some of the common audit targets and mistakes made by physicians and provides strategies for physician practices and health systems to respond to and, ultimately, avoid these denials.