Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 318
Filtrar
1.
J Med Syst ; 43(10): 314, 2019 Sep 07.
Artículo en Inglés | MEDLINE | ID: mdl-31494719

RESUMEN

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.


Asunto(s)
Bases de Datos Factuales/normas , Revisión de Utilización de Seguros/organización & administración , Anciano , Anciano de 80 o más Años , Austria/epidemiología , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/epidemiología , Estudios de Factibilidad , Geriatría , Humanos , Revisión de Utilización de Seguros/normas , Mal Uso de Medicamentos de Venta con Receta/estadística & datos numéricos , Reproducibilidad de los Resultados , Factores Socioeconómicos
3.
Am J Manag Care ; 25(5): e138-e144, 2019 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-31120710

RESUMEN

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.


Asunto(s)
Costos y Análisis de Costo/estadística & datos numéricos , Formulario de Reclamación de Seguro/estadística & datos numéricos , Revisión de Utilización de Seguros/organización & administración , Reembolso de Seguro de Salud/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Colorado , Bases de Datos como Asunto , Femenino , Humanos , Difusión de la Información , Formulario de Reclamación de Seguro/economía , Revisión de Utilización de Seguros/economía , Seguro de Salud/economía , Reembolso de Seguro de Salud/economía , Masculino , Massachusetts , Oregon , Utah
4.
J Eval Clin Pract ; 25(5): 744-750, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31069900

RESUMEN

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.


Asunto(s)
Investigación Biomédica , Revisión de Utilización de Seguros/organización & administración , Mala Praxis , Errores Médicos , Calidad de la Atención de Salud/organización & administración , Investigación Biomédica/ética , Investigación Biomédica/métodos , Investigación Biomédica/normas , Causalidad , Testimonio de Experto/métodos , Testimonio de Experto/normas , Humanos , Jurisprudencia , Conocimiento , Responsabilidad Legal , Mala Praxis/legislación & jurisprudencia , Mala Praxis/estadística & datos numéricos , Errores Médicos/legislación & jurisprudencia , Errores Médicos/prevención & control , Errores Médicos/estadística & datos numéricos , Proyectos de Investigación
5.
Disabil Rehabil ; 41(6): 656-665, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-29145740

RESUMEN

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.


Asunto(s)
Evaluación de la Discapacidad , Revisión de Utilización de Seguros/organización & administración , Reinserción al Trabajo , Ausencia por Enfermedad , Evaluación de Capacidad de Trabajo , Adulto , Femenino , Humanos , Comunicación Interdisciplinaria , Masculino , Persona de Mediana Edad , Investigación Cualitativa , Validez Social de la Investigación , Suecia
6.
Health Policy ; 122(11): 1240-1248, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30220552

RESUMEN

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.


Asunto(s)
Análisis Costo-Beneficio , Atención a la Salud/economía , Administración Hospitalaria/economía , Humanos , Revisión de Utilización de Seguros/economía , Revisión de Utilización de Seguros/organización & administración
7.
Qual Manag Health Care ; 27(3): 165-171, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29944629

RESUMEN

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.


Asunto(s)
Eficiencia Organizacional , Revisión de Utilización de Seguros/organización & administración , Mejoramiento de la Calidad , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/normas , Humanos , Revisión de Utilización de Seguros/economía , Seguro de Salud/economía , Seguro de Salud/organización & administración , Proyectos Piloto , Mejoramiento de la Calidad/organización & administración , Estados Unidos
10.
Diagnosis (Berl) ; 4(3): 125-131, 2017 Sep 26.
Artículo en Inglés | MEDLINE | ID: mdl-29536933

RESUMEN

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.


Asunto(s)
Errores Diagnósticos/estadística & datos numéricos , Revisión de Utilización de Seguros/estadística & datos numéricos , Mala Praxis/estadística & datos numéricos , Radiología , Comunicación , Errores Diagnósticos/economía , Humanos , Revisión de Utilización de Seguros/organización & administración , Responsabilidad Legal , Mala Praxis/economía , Mala Praxis/legislación & jurisprudencia
12.
J Health Econ ; 51: 13-25, 2017 01.
Artículo en Inglés | MEDLINE | ID: mdl-28012299

RESUMEN

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.


Asunto(s)
Revisión de Utilización de Seguros/organización & administración , Mecanismo de Reembolso/organización & administración , Adolescente , Adulto , Capitación/organización & administración , Femenino , Humanos , Seguro de Salud/organización & administración , Masculino , Persona de Mediana Edad , Traumatismos Ocupacionales/clasificación , Traumatismos Ocupacionales/economía , Traumatismos de los Tejidos Blandos/clasificación , Estados Unidos , Indemnización para Trabajadores/organización & administración , Heridas y Lesiones/economía , Adulto Joven
13.
Fed Regist ; 81(242): 90987-97, 2016 12 16.
Artículo en Inglés | MEDLINE | ID: mdl-28030884

RESUMEN

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.


Asunto(s)
Determinación de la Elegibilidad/legislación & jurisprudencia , Determinación de la Elegibilidad/organización & administración , Revisión de Utilización de Seguros/legislación & jurisprudencia , Revisión de Utilización de Seguros/organización & administración , Seguridad Social/legislación & jurisprudencia , Seguridad Social/organización & administración , Evaluación de la Discapacidad , Humanos , Seguro por Discapacidad/legislación & jurisprudencia , Seguro por Discapacidad/organización & administración , Estados Unidos
16.
Hosp Case Manag ; 24(3): 33-4, 2016 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-26964415

RESUMEN

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.


Asunto(s)
Centers for Medicare and Medicaid Services, U.S. , Revisión de Utilización de Seguros/organización & administración , Política Organizacional , Servicios Contratados , Innovación Organizacional , Estados Unidos
18.
Jpn Hosp ; (35): 45-52, 2016 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30226961

RESUMEN

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.


Asunto(s)
Grupos Diagnósticos Relacionados/organización & administración , Procesamiento Automatizado de Datos , Administración Hospitalaria , Revisión de Utilización de Seguros/organización & administración , Bases de Datos Factuales , Política de Salud , Humanos , Japón
19.
J Med Pract Manage ; 31(2): 88-91, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26665475

RESUMEN

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.


Asunto(s)
Auditoría Financiera , Medicaid/economía , Medicare/economía , Administración de la Práctica Médica/economía , Centers for Medicare and Medicaid Services, U.S. , Codificación Clínica , Regulación Gubernamental , Adhesión a Directriz , Humanos , Revisión de Utilización de Seguros/organización & administración , Estados Unidos , Procedimientos Innecesarios/economía
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA