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1.
BMJ ; 367: l6015, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690553

RESUMO

OBJECTIVE: To evaluate the association between gifts from pharmaceutical companies to French general practitioners (GPs) and their drug prescribing patterns. DESIGN: Retrospective study using data from two French databases (National Health Data System, managed by the French National Health Insurance system, and Transparency in Healthcare). SETTING: Primary care, France. PARTICIPANTS: 41 257 GPs who in 2016 worked exclusively in the private sector and had at least five registered patients. The GPs were divided into six groups according to the monetary value of the received gifts reported by pharmaceutical, medical device, and other health related companies in the Transparency in Healthcare database. MAIN OUTCOME MEASURES: The main outcome measures were the amount reimbursed by the French National Health Insurance for drug prescriptions per visit (to the practice or at home) and 11 drug prescription efficiency indicators used by the National Health Insurance to calculate the performance related financial incentives of the doctors. Doctor and patient characteristics were used as adjustment variables. The significance threshold was 0.001 for statistical analyses. RESULTS: The amount reimbursed by the National Health Insurance for drug prescriptions per visit was lower in the GP group with no gifts reported in the Transparency in Healthcare database in 2016 and since its launch in 2013 (no gift group) compared with the GP groups with at least one gift in 2016 (-€5.33 (99.9% confidence interval -€6.99 to -€3.66) compared with the GP group with gifts valued at €1000 or more reported in 2016) (P<0.001). The no gift group also more frequently prescribed generic antibiotics (2.17%, 1.47% to 2.88% compared with the ≥€1000 group), antihypertensives (4.24%, 3.72% to 4.77% compared with the ≥€1000 group), and statins (12.14%, 11.03% to 13.26% compared with the ≥€1000 group) than GPs with at least one gift between 2013 and 2016 (P<0.001). The no gift group also prescribed fewer benzodiazepines for more than 12 weeks (-0.68%, -1.13% to -0.23% compared with the €240-€999 group) and vasodilators (-0.15%, -0.28% to -0.03% compared with the ≥€1000 group) than GPs with gifts valued at €240 or more reported in 2016, and more angiotensin converting enzyme (ACE) inhibitors compared with all ACE and sartan prescriptions (1.67%, 0.62% to 2.71%) compared with GPs with gifts valued at €1000 or more reported in 2016 (P<0.001). Differences were not significant for the prescription of aspirin and generic antidepressants and generic proton pump inhibitors. CONCLUSION: The findings suggest that French GPs who do not receive gifts from pharmaceutical companies have better drug prescription efficiency indicators and less costly drug prescriptions than GPs who receive gifts. This observational study is susceptible to residual confounding and therefore no causal relation can be concluded. TRIAL REGISTRATION: OSF register OSF.IO/8M3QR.


Assuntos
Indústria Farmacêutica/economia , Prescrições de Medicamentos/estatística & dados numéricos , Clínicos Gerais/estatística & dados numéricos , Doações , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Indústria Farmacêutica/estatística & dados numéricos , Prescrições de Medicamentos/economia , Medicamentos Genéricos/economia , Feminino , França , Clínicos Gerais/economia , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Padrões de Prática Médica/economia , Medicamentos sob Prescrição/economia , Estudos Retrospectivos , Adulto Jovem
2.
Spine (Phila Pa 1976) ; 44(22): 1585-1590, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31568265

RESUMO

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.


Assuntos
Descompressão Cirúrgica , Reembolso de Seguro de Saúde , Medicaid , Procedimentos Ortopédicos , Coluna Vertebral/cirurgia , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Procedimentos Ortopédicos/economia , Estados Unidos
3.
Schmerz ; 33(5): 437-442, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31531729

RESUMO

BACKGROUND: On March 10th 2017, the law amending narcotic and other regulations was expanded, thereby allowing physicians, irrespective of their specialization, to prescribe cannabis-derived medicines as magistral formulas or proprietary medicinal products at the expense of the German statutory health insurance (GKV). First prescription requires approval from the respective health insurance, which in turn commissions the Medical Advisory Board of the Statutory Health Insurance Funds (MDK) to prepare a medico-legal report. OBJECTIVES: Since § 31 Para. 6 of the German Social Code, Book V (SGB V) came into effect, a multitude of imponderables have been reported regarding reimbursement. Based on the experience of the MDK Nord, problems within the fields of patients, physicians and cannabis-derived medicines are illustrated. MATERIAL AND METHODS: Considering current literature, a retrospective review was conducted including approximately 2200 applications for reimbursement received in 2018 from patients residing in Hamburg and Schleswig-Holstein. RESULTS: A relevant problem within the field of patients resulted from the lack of a specific definition of the term "severe (chronic) disease". Although this term is mentioned several times in SGB V, it is not put into concrete terms. Circumstances like multimorbidity are not taken into account. Another problem consisted in an irreproducible anticipation of treatment with cannabis-derived medicines. Within the field of physicians, a major problem was caused by missing, fragmentary or inconsistent information regarding disease and/or therapy. Hence, initially, almost one-third of all applications could not be appraised. Amongst various cannabis-derived medicines, dried flowers were found to be the most problematic regarding doses and effective levels. Notably, a marked increase in numbers of applications for reimbursement of therapy with pure cannabidiol was noted. DISCUSSION: Numerous problems reported elsewhere and relating to prescription of cannabis-derived medicines were also observed by the MDK Nord. Many prescriptions reflected an uncertainty regarding therapeutic use of cannabis-derived medicines. Thus, one should consider restricting the prescription of cannabis-derived medicines to selected specialists. It should be noted that, in individual cases, e.g., patients suffering from neuropathic pain, treatment with cannabis-derived medicines seems to be a reasonable therapeutic option taking into account the risks and benefits.


Assuntos
Cannabis , Dor Crônica , Administração Financeira , Reembolso de Seguro de Saúde , Dor Crônica/tratamento farmacológico , Administração Financeira/normas , Administração Financeira/estatística & dados numéricos , Alemanha , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Maconha Medicinal/economia , Maconha Medicinal/uso terapêutico , Estudos Retrospectivos
4.
Infect Dis Poverty ; 8(1): 67, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31370909

RESUMO

BACKGROUND: Tuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the 'China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data. METHODS: In two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10. RESULTS: The nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly. CONCLUSIONS: Although the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Tuberculose/economia , China , Estudos Transversais , Declarações Financeiras/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tuberculose/tratamento farmacológico , Tuberculose/prevenção & controle
5.
Med Care ; 57(10): 801-808, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31464841

RESUMO

OBJECTIVE: To estimate the effect of patient-centered medical home (PCMH) participation on cost and utilization of care for patients in Rhode Island's statewide, multipayer PCMH program, which serves over one-third of the state population. DATA SOURCES/STUDY SETTING: 2009-2014 claims data from all payers in Rhode Island, representing >743,000 unique patients. STUDY DESIGN: A propensity score-matched difference-in-differences framework was used to separately estimate the effect of the PCMH on 3 patient cohorts, which were defined by their intervention start dates and amounts of implementation time. Outcomes included patient costs (total, inpatient, outpatient, professional, pharmacy) and utilization [emergency department (ED) visits, preventable ED visits, inpatient admissions, preventable inpatient admissions, all-cause 30-day readmissions]. Interaction effects were estimated to assess heterogeneity among clinical risk groups and payers. PRINCIPAL FINDINGS: There was no evidence of a PCMH effect on total costs, though we observed evidence of an increase in the odds of PCMH patients having outpatient and professional costs, and in one cohort, a decrease in inpatient costs for those with an inpatient visit. We also observed evidence of reduced ED visits, preventable ED visits, and inpatient admissions for PCMH patients. While subgroup effects varied by cohort and measure, high-risk patients often experienced the largest reductions in ED visits. CONCLUSIONS: All PCMH cohorts experienced statistically significant reductions in some types of utilization in as little as 1.25 years. Reductions were greatest for measures included in the PCMH contractual agreement. While PCMH programs may not expect cost savings in the short-term, costs could potentially be reduced in the longer-term through avoided ED and inpatient expenses.


Assuntos
Utilização de Instalações e Serviços/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Assistência Centrada no Paciente/estatística & dados numéricos , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/economia , Feminino , Implementação de Plano de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente/economia , Avaliação de Programas e Projetos de Saúde , Pontuação de Propensão , Rhode Island
6.
BMJ ; 366: l4109, 2019 07 03.
Artigo em Inglês | MEDLINE | ID: mdl-31270062

RESUMO

OBJECTIVE: To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes. DESIGN: Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims. SETTING: 3238 acute care hospitals in the United States. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334). INTERVENTION: Hospital receipt of a penalty in the first year of the HACRP. MAIN OUTCOME MEASURES: Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality. RESULTS: Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics. CONCLUSIONS: Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.


Assuntos
Hospitais/estatística & dados numéricos , Doença Iatrogênica/prevenção & controle , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Segurança do Paciente/normas , Humanos , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Estados Unidos
8.
Int J Technol Assess Health Care ; 35(3): 229-236, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31218976

RESUMO

Background and ObjectivesTimely access to innovative medical technologies driven by accelerated patient access pathways can substantially improve the health outcomes of patients who often have few therapeutic alternatives. We analyzed lead-times for the medical procedure reimbursement coverage process undertaken in South Korea from 2014 to 2017, which is considered one of the most important factors contributing to delays in patient access to new medical technologies. METHODS: This analysis was performed using the open datasets source of "Medical Procedure Expert Evaluation Committee (MPEEC)" meeting results and medical procedure coverage application information published on the Health Insurance Review and Assessment Service Web site. RESULTS: From 2014 to 2017, 90 percent of all new coverage determinations took on average >250 days with almost 20 percent taking more than 2 years (>750 days), The average lead-time from the medical procedure coverage application to MPEEC meeting in 2015 was 435.0 ± 214.7 days (n = 26), which was significantly shorter than the average lead-time in 2014 (624.9 ± 290.3 days, n = 16) (p < .05). The average lead-time from application to official enforcement in 2015 was significantly shorter than that of 2014 (540.8 ± 217.4; n = 16 versus 734.1 ± 299.7 days; n = 26, respectively) (p < .05). CONCLUSIONS: While this analysis showed a general trend of a reduction in the time taken to receive a positive coverage determination for a new medical technology, the average lead-time remains well over the government mandated 100 days. To continue this trend and further enhance the patient access pathway for medical procedure coverage determinations, some measures can be applied. In particular, the extended "One-Stop Service" program encompassing coverage determinations is one such recommendation that could be considered.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Avaliação da Tecnologia Biomédica/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Qualidade da Assistência à Saúde , República da Coreia , Fatores de Tempo
9.
Health Serv Res ; 54(3): 526-536, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31066468

RESUMO

OBJECTIVE: To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation. DATA SOURCES/STUDY SETTING: Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File. STUDY DESIGN: We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. DATA COLLECTION: Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census. PRINCIPAL FINDINGS: We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. CONCLUSIONS: We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Maryland , Alta do Paciente/estatística & dados numéricos , Estados Unidos
12.
BMC Public Health ; 19(1): 566, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31088561

RESUMO

BACKGROUND: Data are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population. METHODS: Data came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender. RESULTS: Weighted prevalence of BLTU were 2.8%(95% CI:2.3-3.4) and 3.8%(95% CI: 3.3-4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02-1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU. CONCLUSIONS: BLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.


Assuntos
Benzodiazepinas/uso terapêutico , Depressão/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Fatores de Tempo , Adulto , Idoso , Estudos de Coortes , Emprego , Feminino , França/epidemiologia , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Estado Civil , Pessoa de Meia-Idade , Razão de Chances , Prevalência , Sistema de Registros
13.
Brachytherapy ; 18(4): 445-452, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30992185

RESUMO

PURPOSE: The purpose of this study was to quantify the cost of resources required to deliver adjuvant radiation therapy (RT) for high- to intermediate-risk endometrial cancer using time-driven activity-based costing (TDABC). METHODS AND MATERIALS: Comparisons were made for three and five fractions of vaginal cuff brachytherapy (VCB), 28 fractions of intensity-modulated radiation therapy (IMRT), and combined modality RT (25-fraction IMRT followed by 2-fraction VCB). Process maps were developed representing each phase of care. Salary and equipment costs were obtained to derive capacity cost rates, which were multiplied by process times and summed to calculate total costs. Costs were compared with 2018 Medicare physician fee schedule reimbursement. RESULTS: Full cycle costs for 5-fraction VCB, IMRT, and combined modality RT were 42%, 61%, and 93% higher, respectively, than for 3-fraction VCB. Differences were attributable to course duration and number of fractions/visits. Accumulation of cost throughout the cycle was steeper for VCB, rising rapidly within a shorter time frame. Personnel cost was the greatest driver for all modalities, constituting 76% and 71% of costs for IMRT and VCB, respectively, with VCB requiring 74% more physicist time. Total reimbursement for 5-fraction VCB was 40% higher than for 3-fractions. Professional reimbursement for IMRT was 31% higher than for 5-fraction VCB, vs. IMRT requiring 43% more physician TDABC than 5-fraction VCB. CONCLUSIONS: TDABC is a feasible methodology to quantify the cost of resources required for delivery of adjuvant IMRT and brachytherapy and produces directionally accurate costing data as compared with reimbursement calculations. Such data can inform institution-specific financial analyses, resource allocation, and operational workflows.


Assuntos
Braquiterapia/economia , Neoplasias do Endométrio/radioterapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Instalações de Saúde/economia , Recursos em Saúde/economia , Radioterapia de Intensidade Modulada/economia , Braquiterapia/métodos , Braquiterapia/estatística & dados numéricos , Fracionamento da Dose de Radiação , Equipamentos e Provisões/economia , Feminino , Recursos em Saúde/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicare/economia , Radioterapia Adjuvante/economia , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/estatística & dados numéricos , Radioterapia de Intensidade Modulada/métodos , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Salários e Benefícios/economia , Estados Unidos
14.
Tex Med ; 115(3): 20-25, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30855697

RESUMO

Molina Healthcare of Texas isn't the only insurer to give physicians prompt-pay problems, and it won't be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance, which says it's hiring staff and making other changes to improve that response.


Assuntos
Sistemas Pré-Pagos de Saúde/legislação & jurisprudência , Revisão da Utilização de Seguros/legislação & jurisprudência , Reembolso de Seguro de Saúde/estatística & dados numéricos , Médicos/economia , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Governo Estadual , Texas , Fatores de Tempo
16.
Laryngoscope ; 129(10): 2224-2229, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30883780

RESUMO

OBJECTIVES/HYPOTHESIS: Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5-year period. STUDY DESIGN: Retrospective data review. METHODS: This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared. RESULTS: From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non-balloon-based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery. CONCLUSIONS: There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office-based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2224-2229, 2019.


Assuntos
Endoscopia/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Nasais/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sinusite/cirurgia , Idoso , Endoscopia/instrumentação , Endoscopia/métodos , Feminino , Humanos , Masculino , Medicare , Procedimentos Cirúrgicos Nasais/instrumentação , Procedimentos Cirúrgicos Nasais/métodos , Seios Paranasais/cirurgia , Estudos Retrospectivos , Estados Unidos
17.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 725-731, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30763134

RESUMO

Objectives: We analyzed the bid approach of the Hungarian National Health Insurance Fund Administration (NHIFA) based on the results of two consecutive bids on colony stimulating factor (CSF).Methods: The Hungarian NHIFA database was used to analyze the changes in the number of patients treated with CSF and reimbursement paid by NHIFA, 12 months preceding and following the bids.Results: 13,974 patients received granulocyte-CSF treatment during 12 months prior to bidding. A 4.5% decrease (13,352) and further 1.3% decrease (13,185) in the total number of patients were observed during the first and second years, respectively. The annual health insurance subsidy paid during 12 months prior to the bids was. 7.49 billion Hungarian Forint (HUF) or 26.8 million Euro (EUR). In the first year following the bid, we found a 3.3 billion HUF (12.4 million EUR) decrease in health insurance subsidy (44% reduction). A further 7.9% reduction was observed during the second year, resulting in an annual health insurance subsidy of 3.59 billion HUF (12.1 million EUR).Conclusion: During the 2 years bid (public procurement procedure), the National Health Insurance Fund Administration managed to reduce the health insurance subsidy paid for the reimbursement of both original and biosimilar G-CSF products.


Assuntos
Medicamentos Biossimilares/economia , Fator Estimulador de Colônias de Granulócitos/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicamentos Biossimilares/administração & dosagem , Bases de Dados Factuais , Custos de Medicamentos/estatística & dados numéricos , Competição Econômica , Fator Estimulador de Colônias de Granulócitos/administração & dosagem , Humanos , Hungria , Seguro Saúde/economia , Reembolso de Seguro de Saúde/economia , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos
19.
Int J Radiat Oncol Biol Phys ; 104(4): 740-744, 2019 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-30677470

RESUMO

PURPOSE: Insurance payers in the United States vary in the indications for which they consider stereotactic body radiation therapy (SBRT) "medically necessary." We compared changes in policies after the last update to the American Society for Radiation Oncology's (ASTRO) SBRT model policy. METHODS AND MATERIALS: We identified 77 payers with SBRT policies in 2015 from a policy aggregator, as well as 4 national benefits managers (NBMs). Of these, 65 payers and 3 NBMs had publicly available updates since 2015. For each of the indications in ASTRO's model policy, we calculated the proportion of payers that considered SBRT medically necessary. We used Fisher's exact test to compare these proportions between 2015 and now, between policies updated in the past 12 months and those updated less often, and between national and regional payers currently. RESULTS: Payers consider SBRT medically necessary most often for primary lung cancer (97%), reirradiation to the spine (91%), prostate cancer (68%), primary liver cancer (66%), and spinal metastases with radioresistant histologies (66%). Policies have become more aligned with ASTRO's model policy over time. National payers and NBMs cover indications in higher proportions than regional payers. CONCLUSIONS: Although there have been improvements over time, more work is needed to align payer policies with ASTRO's model SBRT policy, especially at the regional level.


Assuntos
Reembolso de Seguro de Saúde/normas , Neoplasias/radioterapia , Política Organizacional , Radioterapia (Especialidade)/normas , Radiocirurgia/economia , Sociedades Médicas/normas , Benchmarking , Humanos , Revisão da Utilização de Seguros/normas , Cobertura do Seguro/normas , Reembolso de Seguro de Saúde/estatística & dados numéricos , Radioterapia (Especialidade)/estatística & dados numéricos , Estados Unidos
20.
J Emerg Med ; 56(3): 352-358, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30638646

RESUMO

BACKGROUND: Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs). OBJECTIVE: Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED. METHODS: Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1 year before and after conversion. RESULTS: There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828). CONCLUSIONS: After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.


Assuntos
Assistência Ambulatorial/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Reembolso de Seguro de Saúde/estatística & dados numéricos , Inovação Organizacional , Vigilância da População/métodos , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/economia , Texas
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