RESUMEN
Cancer pain management can be improved by overcoming patients' attitudinal barriers to reporting pain and using analgesics. A simple cost-effective barriers intervention designed to reach a large number of persons with cancer has not yet been tested. Such an intervention should be tested against barriers' assessment-alone, as well as no-treatment control. The purpose of this study was to test the efficacy and the cost effectiveness of a tailored barriers intervention (TBI), an educational intervention tailored to participants' attitudinal barriers toward reporting pain and using analgesics. This was a randomized three-group (TBI, assessment-alone, or control) trial with measures at baseline and 28 days later conducted at the NorthCentral and Heartland offices of the Cancer Information Service (CIS), an NCI program that provides information to persons seeking answers to cancer-related questions. Participants (1256 adult CIS callers diagnosed with cancer with moderate to severe pain in the past week) joined the study and were randomized. Of these participants, 970 (77.23%) provided follow-up data. The TBI consisted of educational messages tailored to each participant's attitudinal barriers, delivered orally over the telephone, followed by a printed mailed copy. The outcome measures were attitudinal barriers to pain management, as well as pain outcomes (duration, severity, and interference with life activities). At follow-up the TBI group had significantly lower attitudinal barriers scores compared to assessment-alone and control, but the groups did not differ on the pain outcome variables. TBI and assessment-alone had similar cost effectiveness. The TBI needs to be strengthened to achieve reductions in pain severity.
Asunto(s)
Barreras de Comunicación , Promoción de la Salud/métodos , Servicios de Información , Manejo del Dolor , Dolor/psicología , Educación del Paciente como Asunto/métodos , Femenino , Estudios de Seguimiento , Promoción de la Salud/economía , Humanos , Servicios de Información/economía , Masculino , Neoplasias/complicaciones , Neoplasias/psicología , Dolor/etiología , Dimensión del Dolor/métodos , Educación del Paciente como Asunto/economía , Evaluación de Programas y Proyectos de SaludRESUMEN
Substitution of hospital staff performing concurrent utilization review (CUR) was evaluated using a production process framework. There were no differences in the number of reimbursement denials or denied days among 4 job classifications of hospital staff performing CUR, indicating that educational preparation of staff did not affect outcomes. The implications are that hospitals could substitute assistive staff in place of registered nurses to complete the CUR function, potentially increasing the availability of professional nurses.
Asunto(s)
Manejo de Caso/organización & administración , Revisión Concurrente/organización & administración , Personal de Enfermería en Hospital/organización & administración , Servicio Social/organización & administración , Centros Médicos Académicos , Análisis de Varianza , Distribución de Chi-Cuadrado , Educación Continua , Educación de Postgrado , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Medio Oeste de Estados Unidos , Investigación en Evaluación de Enfermería , Personal de Enfermería en Hospital/educación , Evaluación de Procesos y Resultados en Atención de Salud , Competencia Profesional/normas , Rol Profesional , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Salarios y Beneficios , Servicio Social/educaciónRESUMEN
Utilization review (UR) is a strategy used by the managed care industry to monitor and control utilization of health care resources. The concurrent UR process requires that hospital staff report clinical information to payers, who either certify or deny reimbursement. Conflicts may arise when hospital staff disagree with denial decisions. The authors analyzed the various responses of a medical center UR staff to payer denials and found that although denials were not frequent, they were perceived negatively by hospital staff. Improving and standardizing communication among providers, payers, and patients is one means of reducing conflict and frustration in the event of reimbursement denial.
Asunto(s)
Revisión de Utilización de Seguros , Cuerpo Médico de Hospitales/psicología , Mecanismo de Reembolso/organización & administración , Revisión de Utilización de Recursos , Centros Médicos Académicos , Humanos , Entrevistas como AsuntoRESUMEN
The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.
Asunto(s)
Reembolso de Seguro de Salud/estadística & datos numéricos , Revisión de Utilización de Recursos/estadística & datos numéricos , Hospitalización/economía , Humanos , Servicios de Salud MentalRESUMEN
Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.
Asunto(s)
Revisión Concurrente/organización & administración , Evaluación de Resultado en la Atención de Salud/organización & administración , Admisión del Paciente , Manejo de Caso/organización & administración , Comunicación , Control de Costos , Investigación sobre Servicios de Salud , Humanos , Revisión de Utilización de Seguros/organización & administración , Cobertura del Seguro/organización & administración , Programas Controlados de Atención en Salud/organización & administración , Rol de la Enfermera , Admisión del Paciente/economía , Admisión del Paciente/normas , Admisión del Paciente/estadística & datos numéricos , Planificación de Atención al Paciente/organización & administración , Personal de Hospital/psicología , Mecanismo de Reembolso/organización & administración , Estaciones del Año , Encuestas y Cuestionarios , Gestión de la Calidad Total/organización & administraciónAsunto(s)
Anciano Frágil/estadística & datos numéricos , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Servicios de Salud para Ancianos/economía , Hospitalización/economía , Actividades Cotidianas , Distribución por Edad , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Femenino , Asignación de Recursos para la Atención de Salud/métodos , Servicios de Salud para Ancianos/estadística & datos numéricos , Precios de Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Alta del Paciente/estadística & datos numéricos , Estados UnidosRESUMEN
OBJECTIVE: To determine the costs associated with conducting concurrent utilization review, a utilization management strategy widely used by the managed care industry. STUDY DESIGN: A production process model focusing on resource utilization. SUBJECTS: The 29 clinical services of a 500-bed academic health center were aggregated into 9 clinical groups. A random sample of at least 15 reviews per group was studied. METHODS: Time sampling and cost analysis methods were used to determine the cost to the hospital of conducting utilization review. Component activities of the process were identified and analyzed to determine differences among clinical services and among the component tasks of the utilization review process. RESULTS: In 12 months, 13 126 reviews were completed in an average of 15 minutes 41 seconds. Across clinical groups, the average total time of each review ranged from 11 minutes 18 seconds (medical group) to 19 minutes 4 seconds (pediatrics group). Significant differences existed among clinical service groups for the activity of preparing for conducting the review, with the pediatrics group spending more time than the cardiology and oncology groups. The total cost of the process was nearly dollar 166 000 annually. The average cost per review was dollar 11, the average cost per patient-day denied was dollar 478, and the average cost per patient denial was dollar 1592. CONCLUSIONS: These figures are conservative in that they do not include the payer component of the costs, which could be as high as the hospital provider cost. Given a denial rate of < 2% and the high cost of the process, it may be beneficial to investigate alternative processes for conducting utilization review.
Asunto(s)
Centros Médicos Académicos/economía , Centros Médicos Académicos/estadística & datos numéricos , Revisión Concurrente/economía , Costos de Hospital , Revisión Concurrente/estadística & datos numéricos , Costos y Análisis de Costo , Eficiencia Organizacional , Investigación sobre Servicios de Salud , Departamentos de Hospitales/estadística & datos numéricos , Humanos , Programas Controlados de Atención en Salud/estadística & datos numéricos , Modelos Econométricos , Estudios de Tiempo y Movimiento , Estados UnidosRESUMEN
Much of the negative perception of managed care focuses on fear of denials of certification for reimbursement. This study examined more than 50,000 concurrent utilization reviews completed over a four-year period (1998-2001) at a large teaching hospital. The results showed a denial rate of less than 1.5% of all patients reviewed, higher denial rates among certain clinical services, higher rates of reviews among certain services only partially explained by volume of admissions, and a lack of patient criteria to receive care in the inpatient setting as the most frequent reason given for denial.
Asunto(s)
Hospitales de Enseñanza/economía , Revisión de Utilización de Seguros , Reembolso de Seguro de Salud/estadística & datos numéricos , Programas Controlados de Atención en Salud/economía , Revisión Concurrente , Accesibilidad a los Servicios de Salud , Humanos , Cobertura del Seguro , Opinión Pública , Estados UnidosRESUMEN
The production process model is proposed as a way to guide economic evaluation of health care projects, programs, technology, or research. The model is illustrated with data from the development of a home care computer intervention.
Asunto(s)
Implementación de Plan de Salud/economía , Análisis Costo-Beneficio , Modelos Económicos , Atención al Paciente/economíaRESUMEN
A management council can help nurses from various settings of a facility deliver unified care, including inpatient, home health, and surgical services. The University of Wisconsin Hospital's approach can facilitate a management council at your facility.