Feasibility of Mapping Austrian Health Claims Data to the OMOP Common Data Model.

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.

Producing comparable cost and quality results from all-payer claims databases.

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.

Analysis of medical malpractice claims to improve quality of care: Cautionary remarks.

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.

Fair or square? Experiences of introducing a new method for assessing general work ability in a sickness insurance context.

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.

Administrative costs in health care-A scoping review.

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.

Enhancing Financial Performance: An Application of Lean Six Sigma to Reduce Insurance Claim Denials.

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.

The role of radiology in diagnostic error: a medical malpractice claims review.

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.

Claims-shifting: The problem of parallel reimbursement regimes.

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.

Ensuring Program Uniformity at the Hearing and Appeals Council Levels of the Administrative Review Process. Final rule.

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.

CMS gives the RA program a makeover with more changes in store.

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.

Hospitals and Big Data: Use of Case Mix and E-claim Data in Japan.

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.

Hacia un nuevo marco que regule la valoración médica de la capacidad/ incapacidad laboral. Propuestas de mejora y áreas de cambio / Towards a new framework for medical assessment of capacity / incapacity. Proposals for improvement and change areas

CONCLUSIONES: En la incapacidad temporal se hace necesaria la modificación de las entidades y de las competencias de control y seguimiento de la baja. Posibilitar el alta médica parcial para una reincorporación gradual al trabajo tras bajas prolongadas. Compatibilizar baja médica y alta para trabajos con exigencias distintas. Compartir información clínico sanitaria y laboral entre todas las entidades implicadas en la incapacidad temporal. Tarjetas sanitarias que permitan acceso a la historia clínica. Historia clínica única. Ficha de valoración ocupacional (requerimientos laborales) para trabajadores en Incapacidad. En la incapacidad permanente debe de procederse a modificar la composición y competencias del órgano valorador 'EVI equipo de valoración de incapacidades incrementando el componente técnico, médico, preventivo y laboral. Modificar los 'grados' de incapacidad o su valoración en cuanto a baremos lesiones permanentes no invalidantes, incapacidad permanente parcial, la total y la gran invalidez. Modificar el concepto y referencia de profesión habitual ligado al de la incapacidad en seguridad social. Con la evaluación más correcta y completa acorde con los requerimientos del trabajo, incluyendo tareas, sector de la actividad, capacitación, riesgos, y circunstancias especiales del trabajo, Valoración preventiva de la incapacidad y el trabajo. Resolución de controversias entre el no apto y la no incapacidad. Conocer el impacto de la incapacidad tanto temporal como permanente, elaborando un mapa de la incapacidad con los datos básicos para analizar las enfermedades, su consecuencia incapacitante laboral y su presentación en la población. La incapacidad como indicador de salud pública y salud laboral

CONCLUSIONS: Modification of entities and powers of control and monitoring is necessary in low temporary disability. Enable high medical part for a gradual return to work after prolonged low. Compatible medical and high and low for jobs with different requirements. Share health and labor clinical information between all entities involved in temporary disability. health cards that allow access to the medical history. History only clinic. Sheet occupational assessment (job requirements) for workers on disability. In the permanent disability must proceed to change the composition and powers of the titrator body 'EVI disability assessment team increasing the technical component, medical, preventive and labor. Modify the 'degree' of disability or valuation regarding permanent non-disabling injuries scales, permanent partial disability, total and severe disability. Modify the reference concept and usual profession linked to the social security disability. with the most accurate and complete assessment in line with job requirements, including tasks, area of activity, training, risks and special circumstances of the work, preventive assessment of disability and work. Resolution of disputes between unfit and not disability. Knowing the impact of both temporary incapacitation or permanent, preparing a map of the disability with basic data to analyze disease, disabling consequence labor and presentation in the population. The inability as an indicator of public health and occupational health

Problemas derivados de la indeterminación legal de la profesión habitual. Situaciones de compatibilidad no deseadas y propuestas de revisión / Problems arising from the legal profession habitual indeterminacy. Compatibility unwanted situations and proposed revisions

La determinación de la profesión habitual se configura como una de las piezas clave del sistema por el que se rige la declaración de invalidez permanente. Lo es porque determina tanto la procedencia de la declaración inicial de la invalidez, de manera fundamental en la incapacidad permanente total, como la compatibilidad de la misma una vez reconocida con el trabajo, con un salario o con una posible prestación futura derivada del mismo. La indeterminación legal de los parámetros que configuran el reconocimiento de una situación de invalidez deriva, en situaciones de compatibilidad difíciles de justificar. Sin duda la más sorprendente es la prácticamente absoluta compatibilidad de la situación de incapacidad permanente absoluta y de gran invalidez con el trabajo, según la doctrina configurada por el Tribunal Supremo. También hay dificultad para revisar el grado de incapacidad reconocido, puesto que la misma ha de ajustarse a los motivos tasados por el legislador. CONCLUSIONES: - Delimitar el concepto de profesión habitual de una forma de manera que se amplíe desde el marco reducido de las funciones al más amplio del grupo profesional o, cuando menos, al que habilita al empresario para efectuar la movilidad funcional. - Modificar las actuales causas de revisión de la invalidez posibilitando que la mejoría también pueda ser considerada desde la perspectiva profesional, bien por la adaptación y rehabilitación funcional posterior o bien porque las modificaciones de los procesos productivos modifiquen la capacidad profesional inicialmente determinada. - Determinar en supuestos de nuevo trabajo si es compatible con las limitaciones funcionales objetivadas e impedir así el desempeño de trabajos con requerimientos similares o superiores a los que provocaron el reconocimiento de la situación de IPT. - Suspender la pensión de IPT en el supuesto de que el beneficiario de la misma simultaneé su percibo con el desempeño de la misma profesión, o funciones, o de otras que exijan los mismos requerimientos que aquella para la que fue declarado inválido. - Vincular la declaración de IPT a planes de formación para la búsqueda de empleo y rehabilitación ocupacional, asociando el percibo de la prestación por IPT a la búsqueda activa de empleo mediante la obligatoriedad de participar en programas de formación destinados a facilitar la reincorporación a la vida laboral activa. - Valoración de la incidencia de la edad y la formación en el reconocimiento de las situaciones de incapacidad permanente. - Profundizar en el análisis del paralelismo o correlación entre las prestaciones de desempleo y de IPT

Determining the usual profession it is configured as one of the key parts of the system by which the declaration of permanent disability is governed. It is because it determines both the origin of the initial declaration of invalidity, fundamentally in the total permanent disability, such as support of it once awarded the job, with a salary or a possible future benefit arising therefrom. The legal uncertainty of the parameters that make up the recognition of a situation of invalidity stems in difficult situations justify compatibility. Undoubtedly the most striking is the almost complete compatibility of the situation of absolute permanent disability and severe disability to work, according to the doctrine set by the Supreme Court. There is also difficulty revising the recognized degree of disability, since it must comply with the reasons assessed by the legislature. CONCLUSIONS: - Define the concept of habitual profession in a way so that it extends from the small part of the broader functions of the professional group or at least, which enables the employer to make functional mobility. - Modify the current review of the causes of disability enabling the improvement also can be considered from the professional perspective, either by post or adaptation and functional rehabilitation because changes in production processes initially determined modify the professional capacity. - Determine in cases of new job if it is compatible with the objectified functional limitations and thus prevent the performance of similar or higher work requirements that led to the recognition of the status of IPT. - Suspend IPT pension in the event that the beneficiary of the juggled her perceive with the performance of the same profession, or functions, or other requiring the same requirements as that for which was declared invalid. - Linking statement IPT training plans for job search and occupational rehabilitation, associating collect the benefit for IPT to active job search by mandatory to participate in training programs to facilitate the return to life active labor. - Assessment of the impact of age and training in recognizing situations of permanent disability. - Deepen the parallelism analysis or correlation between unemployment benefits and IPT