[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

Government regulation of pricing and reimbursement of prescription medicines: results of a recent multi-country review.

Access to prescription medicines is an essential component of publicly funded or publicly assisted healthcare programs. Thus, important policy questions are presented when government agencies that administer those programs establish procedures for making decisions about the appropriate use of medicines, including determinations as to which medicines will be reimbursed, at what prices, and for which patients. The authors reviewed systems for making determinations on pricing and reimbursement of prescription medicines under public healthcare systems in 10 countries, including four member states of the European Union (EU) (France, Germany, Italy and the United Kingdom), plus Australia, Brazil, China, India, Japan and Korea. In addition to national regulatory requirements, the authors considered international agreements that may impose obligations with respect to procedures for pricing and reimbursement of prescription medicines, including the EU's Transparency Directive, agreements administered by the World Trade Organization (WTO), and bilateral free trade agreements negotiated by the United States in recent years. Drawing on this experience, the authors sought to identify common themes, pitfalls and best practices in national systems for regulating pricing and reimbursement of prescription medicines. The authors have focused primarily on procedures, rather than the underlying political assumptions or substantive economic objectives. They have assumed that all countries have--or should have--a common interest in assuring that decision-making procedures afford interested persons who have relevant information a meaningful opportunity to participate

Toward greater equity and efficiency in rate setting: the adult residential rehabilitation programs in Massachusetts.

In FY 2001, the Massachusetts Bureau of Substance Abuse Services contracted with 64 adult-only residential rehabilitation facilities. All were paid on an undifferentiated class rate basis at $55 per resident-day. This study uses cost and other information from program-submitted Uniform Financial Reports to measure the facility-specific costs of providing residential rehabilitation services, distinguish the program and site-specific factors responsible for the facility cost differences, and then use this information to suggest alternative, more equitable, and more efficient approaches to rate setting. This analysis finds that a uniform rate structure is substantially inefficient and inequitable.

How much is enough? An evidence-based framework for setting Medicaid payment rates.

This article proposes an evidence-based framework for Medicaid programs to use in setting payment levels for any health care service. The purpose of payment is seen from the beneficiary's perspective, that is, enabling access to quality services. The approach is to measure access as directly as possible, to make findings about payment adequacy, and to take action in a way that maximizes the return (i.e., access to quality care) on Medicaid's investment. This approach differs from both the theoretical ideal and from much of the past practice in Medicaid rate setting. The paper offers examples of evidence, findings, and actions.

Medicare and Medicaid managed care: a tale of two trajectories.

Two decades of efforts to promote managed care models in Medicare and Medicaid have resulted in vastly different experiences as measured by enrollment, plan participation, and ability to achieve the goals of public policy-makers. The Medicare Modernization Act of 2003 introduced a major transformation to engage and retain private health plans. It is useful for plan administrators to consider why the trajectories for the programs have been so divergent and to assess prospects for success in the Medicare Advantage initiative.

The economics of prescription drug prices, government intervention, and the importation of drugs from Canada.

Popular attention has focused on the skyrocketing health care costs in the United States and specifically on increasing insurance and prescription drug prices. Individuals and some local governments have advocated importing price-controlled prescription drugs from Canada to help ease the financial burden. What effects would this have on consumer prices, drug companies' incentives, and the development of new medications?

Compromisos de gestión de hospitales: un análisis del sistema de pago desde la perspectiva de gestión asistencial y algunas propuestas de mejora / Commitments of management of hospitals: an analysis of the system of payment from the perspective

Introducción: El sistema de pago a los centros hospitalarios es un punto medular dentro del proceso de compra, dado que condiciona los servicios de salud entres elementos fundamentales: la demanda, la oferta y la gestión de los servicios. En este sentido, cada método de pago conlleva un conjunto de incentivos que estimula a los hospitales a comportarse de manera específica en términos de los tipos, cantidades y calidad de los servicios que ofrecen. Objetivo: El objetivo del trabajo es analizar algunos resultados obtendios con la implementación del proceso de compra de servicios de salud dentro de la CCSS a la luz de algunos elementos de sistema de pago más robustos y de los conceptos de gestión de procesos asistenciales. Diseño: El tipo de investigación implementado es el analítico-descriptivo basado en la revisión bibliográfica y la consideración de algunas experiencias internacionales en los procesos de Contratos Programa. Resultados: Los resultados muestran que los hospitales no han modificado su comportamiento en relación con la gestión de los casos. A nivel de hospitales nacionales, en promedio la estancia media se incrementa, a pesar de que con la disminución del estándar se pretendía que la duración de los casos disminuyera. El índice de complejidad es muy diferente entre centros de un mismo nivel de complejidad y además no ha presentado un incremento sostenido en los últimos años. El porcentaje de consultas de primera vez (que corresponden a personas atendidas) fue en promedio del 20.4 por ciento en el período 2001-2003, lo que implica que casi el doble de personas recibió una consulta especializada, respecto de que debió atenderse. Conclusiones: E pago por UPH, no ha resultado un buen sistema para motivar una mejor resolución de los casos atendidos en el hospital, dado que la financiación a recibir está directamente relacionada con el número de estancias, independientemente de los servicios y la atención que preste realmente al paciente...