Trends in Insurance Coverage for Complementary Health Care Services.

Introduction: Complementary health care professionals deliver a substantial component of clinical services in the United States, but insurance coverage for many such services may be inadequate. The objective of this project was to follow up on an earlier single-year study with an evaluation of trends in reimbursement for complementary health care services over a 7-year period. Methods: The authors employed a retrospective serial cross-sectional design to analyze health insurance claims for services provided by licensed acupuncturists, chiropractors, and naturopaths in New Hampshire (NH) from 2011 to 2017. They restricted the analyses to claims in nonemergent outpatient settings for Current Procedural Terminology code 99213, which is one of the most commonly used clinical procedure codes across all specialties. They evaluated by year the likelihood of reimbursement, as compared with primary care physicians as the gold standard. A generalized estimating equation model was used to account for within-person correlations among the separate claim reimbursement indicators for individuals used in the analysis, using an exchangeable working covariance structure among claims for the same individual. Reimbursement was defined as payment >0 dollars. Results: The total number of clinical services claimed was 26,725 for acupuncture, 8317 for naturopathic medicine, 2,539,144 for chiropractic, and 1,860,271 for primary care. Initially, likelihood of reimbursement for naturopathic physicians was higher relative to primary care physicians, but was lower from 2014 onward. Odds of reimbursement for both acupuncture and chiropractic claims remained lower throughout the study period. In 2017, as compared with primary care the likelihood of reimbursement was 77% lower for acupuncturists, 72% lower for chiropractors, and 64% lower for naturopaths. Conclusion: The likelihood of reimbursement for complementary health care services is significantly lower than that for primary care physicians in NH. Lack of insurance coverage may result in reduced patient access to such services.

Reducing avoidable chest pain admissions and implementing high-sensitivity troponin testing.

NHS accident and emergency departments see 0.5 million patients presenting with a cardiac condition each year. The accurate assessment of chest pain and subsequent diagnosis or exclusion of myocardial infarction (MI) represent a significant challenge, with important consequences on patient outcome and healthcare resources. We conducted a cross-sectional analysis of patients admitted with cardiac chest pain to a busy district general hospital in London. The criteria used by physicians to admit patients for further cardiac investigations were measured against national guidance on chest pain assessment and diagnosis of MI. We found that poor adherence to guidance, unsuitable patient pathways and inappropriate diagnostic tools at the point of presentation led to unnecessary inpatient admissions to the hospital. Quality improvement methods were used with the aim to reduce avoidable admissions to hospital in patients presenting with chest pain. We describe a system to implement new high-sensitivity troponin testing into legacy chest pain pathways. This was achieved through local education of National Institute for Health and Care Excellence (NICE) guidance, the use of patient pro formas and the creation of two new chest pain pathway arms to enable physicians to streamline patients for appropriate inpatient or outpatient care. As a result of these changes, we reduced non-compliance with NICE guidance by 83% and achieved a 42% reduction in avoidable chest pain admissions. Overall, the improvements made by this project were sustained over 2 years and saved £21 000 per month in avoidable admissions.

At-risk registers integrated into primary care to stop asthma crises in the UK (ARRISA-UK): study protocol for a pragmatic, cluster randomised trial with nested health economic and process evaluations.

BACKGROUND: Despite effective treatments and long-standing management guidelines, there are approximately 1400 hospital admissions for asthma weekly in the United Kingdom (UK), many of which could be avoided. In our previous research, a secondary analysis of the intervention (ARRISA) suggested an improvement in the management of at-risk asthma patients in primary care. ARRISA involved identifying individuals at risk of adverse asthma events, flagging their electronic health records, training practice staff to develop and implement practice-wide processes of care when alerted by the flag, plus motivational reminders. We now seek to determine the effectiveness and cost-effectiveness of ARRISA in reducing asthma-related crisis events. METHODS: We are undertaking a pragmatic, two-arm, multicentre, cluster randomised controlled trial, plus health economic and process evaluation. We will randomise 270 primary care practices from throughout the UK covering over 10,000 registered patients with 'at-risk asthma' identified according to a validated algorithm. Staff in practices randomised to the intervention will complete two 45-min eLearning modules (an individually completed module giving background to ARRISA and a group-completed module to develop practice-wide pathways of care) plus a 30-min webinar with other practices. On completion of training at-risk patients' records will be coded so that a flag appears whenever their record is accessed. Practices will receive a phone call at 4 weeks and a reminder video at 6 weeks and 6 months. Control practices will continue to provide usual care. We will extract anonymised routine patient data from primary care records (with linkage to secondary care data) to determine the percentage of at-risk patients with an asthma-related crisis event (accident and emergency attendances, hospitalisations and deaths) after 12 months (primary outcome). We will also capture the time to crisis event, all-cause hospitalisations, asthma control and any changes in practice asthma management for at-risk and all patients with asthma. Cost-effectiveness analysis and mixed-methods process evaluations will also be conducted. DISCUSSION: This study is novel in terms of using a practice-wide intervention to target and engage with patients at risk from their asthma and is innovative in the use of routinely captured data with record linkage to obtain trial outcomes. TRIAL REGISTRATION: ISRCTN95472706 . Registered on 5 December 2014.

[Costs associated with multiresistant bacteria in neurorehabilitation]. / Mehrkosten durch multiresistente Erreger in der Neurorehabilitation.

BACKGROUND AND OBJECTIVES: The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB. MATERIALS AND METHODS: To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany. RESULTS: On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB. CONCLUSIONS: Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

An analysis of the economic and patient outcome impact of an integrated COPD service in east London.

Exacerbations of COPD carry a huge burden of morbidity and a significant economic impact. It has been shown that home care may be useful for exacerbations of COPD. This article presents a review of an integrated COPD service in east London. Hospital Episode Statistics, Public Health Mortality Files and clinical data were used to analyze differences in health care usage and COPD patient outcomes, including COPD assessment test (CAT) scores for a subsample, before and after the introduction of the integrated service. There was a significant (30%) reduction in the number of hospital bed days for COPD patients (P<0.05), alongside a significant increase in patients with only a short stay (0-1 days) in hospital (P<0.0001). There was a significant increase in the number of patients dying outside of hospital (a proxy for quality of end-of-life care) following introduction of the service (P=0.00015). Patients also reported a clinically significant improvement in CAT scores. A locally developed economic model shows that the economic benefits of the service (via impact on place of death and reduction in length of hospital stay) were almost equal to the cost of the service. The increase in proportion of short-stay admissions and the reduction in bed days suggest an impact of the service on early supported discharge and that this along with an improvement in patient clinical outcomes and in quality of end-of-life care shows that an exemplar integrated COPD service can provide benefits that equate to a nearly cost-neutral service.

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations.

AIM: To estimate potential savings for Australia's health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes. METHODS: A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes. RESULTS: 327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year. CONCLUSIONS: The differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.

Reducing the length of postnatal hospital stay: implications for cost and quality of care.

BACKGROUND: UK health services are under pressure to make cost savings while maintaining quality of care. Typically reducing the length of time patients stay in hospital and increasing bed occupancy are advocated to achieve service efficiency. Around 800,000 women give birth in the UK each year making maternity care a high volume, high cost service. Although average length of stay on the postnatal ward has fallen substantially over the years there is pressure to make still further reductions. This paper explores and discusses the possible cost savings of further reductions in length of stay, the consequences for postnatal services in the community, and the impact on quality of care. METHOD: We draw on a range of pre-existing data sources including, national level routinely collected data, workforce planning data and data from national surveys of women's experience. Simulation and a financial model were used to estimate excess demand, work intensity and bed occupancy to explore the quantitative, organisational consequences of reducing the length of stay. These data are discussed in relation to findings of national surveys to draw inferences about potential impacts on cost and quality of care. DISCURSIVE ANALYSIS: Reducing the length of time women spend in hospital after birth implies that staff and bed numbers can be reduced. However, the cost savings may be reduced if quality and access to services are maintained. Admission and discharge procedures are relatively fixed and involve high cost, trained staff time. Furthermore, it is important to retain a sufficient bed contingency capacity to ensure a reasonable level of service. If quality of care is maintained, staffing and bed capacity cannot be simply reduced proportionately: reducing average length of stay on a typical postnatal ward by six hours or 17% would reduce costs by just 8%. This might still be a significant saving over a high volume service however, earlier discharge results in more women and babies with significant care needs at home. Quality and safety of care would also require corresponding increases in community based postnatal care. Simply reducing staffing in proportion to the length of stay increases the workload for each staff member resulting in poorer quality of care and increased staff stress. CONCLUSIONS: Many policy debates, such as that about the length of postnatal hospital-stay, demand consideration of multiple dimensions. This paper demonstrates how diverse data sources and techniques can be integrated to provide a more holistic analysis. Our study suggests that while earlier discharge from the postnatal ward may achievable, it may not generate all of the anticipated cost savings. Some useful savings may be realised but if staff and bed capacity are simply reduced in proportion to the length of stay, care quality may be compromised.

A Better Approach to PARKINSON'S.

People with Parkinson's disease are admitted to the hospital 50 percent more than their peers and experience longer hospital stays. Can teams of providers and patients, working mostly outside the hospital, improve care and save costs?

[Concept of an interdisciplinary emergency department at the Schwarzwald-Baar Hospital]. / Konzept einer interdisziplinären Notaufnahmeklinik am Schwarzwald-Baar Klinikum.

BACKGROUND: Numerous hospitals were combined years ago into a new Central Hospital for cost reasons in the Schwarzwald-Baar region. This also suggested the idea of a large central emergency department. The concept of a central emergency department is an organizational challenge, since they are directly engaged in the organizational structure of all medical departments that are involved in emergency treatment. Such a concept can only be enforced if it is supported by hospital management and all parties are willing to accept interdisciplinary and interprofessional work. OBJECTIVE: In this paper, the concept of a central emergency department in a tertiary care hospital which was rebuilt as an organizationally independent unit is described. Collaborations with various departments, emergency services, and local physicians are highlighted. The processes of a central emergency department with an integrated admission department and personnel structures are described. CONCLUSION: The analysis of the concept after almost a year has shown that the integration into the clinic has been successful, the central emergency department has proven itself as a central hub and has been accepted as a unit within the hospital.

Exploring parent views of community matrons.

The children's national service framework advocates children's services being designed and delivered around the needs of the child. This article details parental perception of and satisfaction with a paediatric community matron service that aims to reduce emergency admission of children aged 0-16 with respiratory disease. Parents valued the individualised holistic relationship formed between the community matron, child and family. One in four said their child's hospital attendance was reduced.

Effect of a clinical pathway on length of stay and cost of pediatric inpatient asthma admissions: an integrative review.

Asthma is the leading cause of pediatric hospital admissions in the United States. In response to the high prevalence of asthma and the variations in care, clinical practice guidelines have been developed and recommend the use of a clinical pathway for inpatient management. This review will examine the effects of a pediatric asthma clinical pathway on inpatient stays, specifically the length of stay (LOS) and cost of inpatient admissions. A literature review was performed to identify original research projects examining the effects of an asthma clinical pathway on inpatient pediatric admissions. Nine studies were found to fit the criteria and are included in this review. These nine studies found consistent evidence that the use of an asthma clinical pathway for inpatient asthma admissions resulted in reduced LOS and cost.

Avoiding inappropriate paediatric admission: facilitating General Practitioner referral to Community Children's Nursing Teams.

BACKGROUND: Children's emergency admissions in England are increasing. Community Children's Nursing Teams (CCNTs) have developed services to manage acutely ill children at home to reduce demand for unscheduled care. Referral between General Practitioners (GPs) and CCNTs may reduce avoidable admissions and minimise the psychosocial and financial impact of hospitalisation on children, families and the NHS. However, facilitators of GP referral to CCNTs are not known. The aim of this study was to identify facilitators of GP referral to CCNTs. METHODS: Semi-structured interviews with 39 health professionals were conducted between June 2009 and February 2010 in three Primary Care Trusts served by CCNTs in North West England. Interviewees included GPs, Community Children's Nurses (CCNs), consultant paediatricians, commissioners, and service managers. Qualitative data were analysed thematically using the Framework approach in NVivo 8. RESULTS: Five facilitators were identified: 1) CCN/CCNT visibility; 2) clear clinical governance procedures; 3) financial and organisational investment in the role of CCNTs in acute care pathways; 4) access and out of hours availability; 5) facilitative financial frameworks. CONCLUSION: GPs required confidence in CCNs' competence to safely manage acutely ill children at home and secure rapid referral if a child's condition deteriorated. Incremental approaches to developing GP referral to CCNTs underpinned by clear clinical governance protocols are likely to be most effective in building GP confidence and avoiding inappropriate admission.

The financial burden of mandibular trauma.

PURPOSE: Patients with mandibular trauma in the greater Seattle region are frequently transferred to Harborview Medical Center (HMC) despite trained providers in the surrounding communities. HMC receives poor reimbursement for these services, creating a disproportionate financial burden on the hospital. In this study we aim to identify the variables associated with increased cost of care, measure the relative financial impact of these variables, and quantify the revenue loss incurred from the treatment of isolated mandibular fractures. MATERIALS AND METHODS: A retrospective chart review was conducted of patients treated at HMC for isolated mandibular fractures from July 1999 through June 2010, using International Classification of Diseases, Ninth Revision and Current Procedural Terminology coding. Data collected included demographics, injury, hospital course, treatment, outcomes, and billing. RESULTS: The study included 1,554 patients. Total billing was $22.1 million. Of this, $6.9 million was recovered. We found that there are multiple variables associated with the increased cost of treating mandibular fractures; 4 variables--length of hospital stay, treatment modality, service providing treatment, and method of arrival--accounted for 49.1% of the total variance in the amount billed. In addition, we found that the unsponsored portion of our patient population grew from 6.7% to 51.4% during the study period. CONCLUSIONS: Our results led to specific cost-efficiency recommendations: 1) perform closed reduction whenever possible; 2) encourage performing procedures with patients under local anesthesia (closed reductions and arch bar removals); 3) provide improved and shared training among the services treating craniofacial trauma; 4) encourage arrival by privately owned vehicle; 5) provide outpatient treatment, when applicable; 6) offer provider incentives to take trauma call; and 7) offer hospital incentives to treat patients and not transfer them.

[Outpatient rehabilitation after myocardial infarction or for heart failure]. / Ambulante Rehabilitation nach Herzinfarkt und bei Herzinsuffizienz.

Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.

Care coordination for children with complex care needs significantly reduces hospital utilization.

PURPOSE: The purpose was to evaluate an ambulatory care coordination program for children with complex care needs. DESIGN AND METHODS: A pre- and postcohort evaluation design was implemented to analyze the impact on hospital utilization. RESULTS: Results included a decrease in emergency department presentations (15%, p < .001), hospital admissions (9%, p < .019), and hospital bed days (43%, p < .001). Economic analysis indicated a cost savings of $A 1.9 million per annum. PRACTICE IMPLICATIONS: Hospital utilization is significantly reduced for children with complex care needs through 24/7 care coordination.

Induction-related cost of patients with acute myeloid leukaemia in France.

OBJECTIVE: The economic profile of acute myeloid leukaemia (AML) is badly known. The few studies published on this disease are now relatively old and include small numbers of patients. The purpose of this retrospective study was to evaluate the induction-related cost of 500 patients included in the AML 2001 trial, and to determine the explanatory factors of cost. SETTING: "Induction" patient's hospital stay from admission for "induction" to discharge after induction. METHOD: The study was performed from the French Public Health insurance perspective, restrictive to hospital institution costs. The average management of a hospital stay for "induction" was evaluated according to the analytical accounting of Besançon University Teaching Hospital and the French public Diagnosis-Related Group database. Multiple linear regression was used to search for explanatory factors. MAIN OUTCOME MEASURE: Only direct medical costs were included: treatment and hospitalisation. RESULTS: Mean induction-related direct medical cost was estimated at €41,852 ± 6,037, with a mean length of hospital stay estimated at 36.2 ± 10.7 days. After adjustment for age, sex and performance status, only two explanatory factors were found: an additional induction course and salvage course increased induction-related cost by 38% (± 4) and 15% (± 1) respectively, in comparison to one induction. These explanatory factors were associated with a significant increase in the mean length of hospital stay: 45.8 ± 11.6 days for 2 inductions and 38.5 ± 15.5 if the patient had a salvage course, in comparison to 32.9 ± 7.7 for one induction (P < 10⁻4). This result is robust and was confirmed by sensitivity analysis. CONCLUSION: Consideration of economic constraints in health care is now a reality. Only the control of length of hospital stay may lead to a decrease in induction-related cost for patients with AML.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

[Comparison of treatment expenses of naturopathic and orthopedic in-patient treatment]. / Kostenvergleichsuntersuchung zur naturheilkundlichen und konventionellen orthopädischen stationären Behandlung.

BACKGROUND: In health services research comparative studies between orthopaedics and naturopathy are necessary. They allow evidence based decisions between individual therapeutical alternatives as well as decisions on health politics, e.g. concerning allocation of resources. PATIENTS AND METHODS: A controlled prospective cohort study is presented. Conservatively treated patients were recruited for the study, if they needed in-patient treatment because of chronic back pain. The conservative orthopaedic treatment including Minimal invasive Therapy (MIT) was compared to in-patient naturopathic "complex"-treatment. The real costs to the public health insurance system are unknown--relating to both the individual patient and the physician. Hence an approximation was attempted on the basis of the billing of the concerned hospitals, the analysis of extensive patient interviews, randomly selected evaluation of in- and out-patient records, validated by an expert panel. RESULTS: Costs for medication decreased in the post stationary phase after orthopedic and naturopathic treatment. Rehabilitation measures and treatments at a health resort increased after orthopedic treatment, whereas the frequency of specialist consultation decreased in both cohorts indicating the efficacy of the in-patient treatment. Incidence of psychotherapy was highest in the naturopathic group before admission to hospital and decreased afterwards. The gathered data point to a reduction of the total outpatient treatment costs in both cohorts. There were treatment-specific differences when regarding single components. CONCLUSION: Naturopathic complex in-patient treatment is a cost-efficient complement of the conventional orthopedic treatment options.