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.

Patient and facility variation in costs of catheter ablation for atrial fibrillation

BACKGROUND

Cost-effectiveness or value of cardiovascular therapies may be undermined by unwarranted cost variation, particularly for heterogeneous procedures such as catheter ablation for atrial fibrillation (AF). We sought to characterize cost variation of AF ablation in the US healthcare system and the relationship between cost and outcomes.

METHODS AND RESULTS

We performed a retrospective cohort study using data from the MarketScan® commercial claims and Medicare supplemental databases including patients who received an AF ablation from 2007 to 2011. We aggregated encounter cost, reflecting total payments received for the encounter, to the facility level to calculate median facility cost. We classified procedures as outpatient or inpatient and assessed for association between cost and 30-day and 1-year outcomes. The analysis cohort included 9,415 AF ablations (59±11 years; 28% female; 52% outpatient) occurring at 327 facilities, with large cost variation across facilities (median: $25,100; 25th percentile: $18,900, 75th percentile: $35,600, 95th percentile: $57,800). Among outpatient procedures, there was reduced healthcare utilization in higher cost quintiles with reductions in rehospitalization at 30-days (Quintile 1: 16.1%, Quintile 5: 8.8%, P < 0.001) and 1-year (Quintile 1: 34.8%, Quintile 5: 25.6%, P < 0.001), which remained significant in multivariate analysis.

CONCLUSIONS

Although median costs of AF ablation are below amounts used in prior cost-effectiveness studies that demonstrated good value, large facility variation in cost suggests opportunities for cost reduction. However, for outpatient encounters, association of cost to modestly improved outcomes suggests cost containment strategies could have variable effects.

Drivers of Healthcare Costs Among the Costliest Patients With Psoriasis Over Three Years in a United States Health Plan

<p>OBJECTIVE: To compare patients with psoriasis by cost level over 3 years.</p> <p>METHODS: Psoriasis patients in a large US health plan in 2011-2013 were identified. Four groups were created by healthcare costs excluding biologics: patients having top 10% of costs in all 3 years (Top), top 10% in 2 of 3 years (High), bottom 90% in 2 of 3 years (Medium), and bottom 90% in all 3 years (Bottom). Comorbidities, utilization, and costs between groups were compared.</p> <p>RESULTS: The study included 18,653 patients: 514 (3%), 805 (4%), 2,443 (13%), and 14,891 (80%) patients in the Top, High, Medium, and Bottom groups, respectively. Significantly more patients in the Top vs Bottom group had diabetes (31.1% vs 9.4%), cardiovascular disease (26.5% vs 4.3%), psoriatic arthritis (25.7% vs 10.7%), depression (27.8% vs 6.9%), and anxiety (22.0% vs 7.9%) in 2011 (all P less than 0.05). Patients in the Top group had more unique 2011 prescriptions (17.7 vs 6.6; P less than 0.001) than the Bottom group, but similar biologic use (22.4% vs 21.6%). Patients in the Top, High, Medium, and Bottom groups had mean 2011 total costs of $68,913, $40,575, $24,292, and $8,815, and contributed to 14%, 13%, 23%, and 51% of the overall costs, respectively. Mean total costs increased 14-18% over time for all groups. Although mean 2011 total costs for patients in the Top group were 7.8 times of those in the Bottom group, psoriasis-related costs were less disparate ($8,716 vs $4,541). Compared with patients in the Bottom group, those in the Top group were more likely to have any 2011 hospitalization (36.8% vs 2.6%; psoriasis-related: 11.1% vs 0.7%) or emergency visit (50.8% vs 20.8%; psoriasis-related: 3.9% vs 1.0%).</p> <p>CONCLUSION: The costliest patients with psoriasis had significantly higher prevalence of comorbidities, prescription fills, inpatient and emergency utilization, but not biologic medication use or biologic costs.</p> <p><em>J Drugs Dermatol. 2017;16(7):651-658.</em></p>.

The Changing Face of Healthcare: 2016 CPT Changes and Beyond

This article reviews the changes to CPT 2016, with emphasis on the way CPT services will be provided in the future. Some of the newer codes are designed for reimbursable services provided by the medical clinical staff. In addition to the CPT changes, there are changes to the Medicare fee-for service Physician Fee Schedule. Review of these changes provides the reader with a snapshot of how healthcare will be provided and reimbursed in the future.

Dental treatment injuries in the Finnish Patient Insurance Centre in 2000-2011

Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000-2011. The injury cases were grouped as (K00-K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant's age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000-2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71-2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.

What explains DRG upcoding in neonatology? The roles of financial incentives and infant health

We use the introduction of diagnosis related groups (DRGs) in German neonatology to study the determinants of upcoding. Since 2003, reimbursement is based inter alia on birth weight, with substantial discontinuities at eight thresholds. These discontinuities create incentives to upcode preterm infants into classes of lower birth weight. Using data from the German birth statistics 1996-2010 and German hospital data from 2006 to 2011, we show that (1) since the introduction of DRGs, hospitals have upcoded at least 12,000 preterm infants and gained additional reimbursement in excess of 100 million Euro; (2) upcoding rates are systematically higher at thresholds with larger reimbursement hikes and in hospitals that subsequently treat preterm infants, i.e. where the gains accrue; (3) upcoding is systematically linked with newborn health conditional on birth weight. Doctors and midwives respond to financial incentives by not upcoding newborns with low survival probabilities, and by upcoding infants with higher expected treatment costs.

Higher rate of compensation after surgical treatment versus conservative treatment for acute Achilles tendon rupture

INTRODUCTION

Acute Achilles tendon rupture (ATR) can be treated either surgically or non-surgically. High-quality meta-analyses show a lower re-rupture rate, but a higher overall complication rate among surgically treated patients. No studies have evaluated the socio-economic impact of different complications. The aim of this study was to investigate: 1) the socio-economic impact of complications after ATR through the utilisation of the Danish Patient Insurance Association (DPIA) database, 2) correlations between treatment and complications.

METHODS

A total of 324 patients with ATR reported in the period from 1992 to 2010 in the DPIA database were identified and patient records were reviewed manually.

RESULTS

The compensation awarded for the 18-year period totalled 18,147,202 DKK with 41% of patient claims being recognised. Out of 180 surgically treated patients, 79 received a total compensation of 14,051,377 DKK, median 47,637 (range: 5,000-3,577,043). Of 114 non-surgically treated patients, 40 received 3,715,224 DKK in compensation, with a median amount of 35,788 DKK (range: 5,000-830,073).

CONCLUSION

Compensation after surgical treatment was 3.8 times higher than compensation after non-surgical treatment. It is noteworthy that 34.5% of patients had an overlooked diagnosis which underlines the importance of a correct primary diagnosis.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Outcomes after hip arthroscopy in patients with workers' compensation claims

Patients with a workers' compensation claim have been shown to have inferior outcomes after various orthopedic procedures. In hip arthroscopy, good to excellent results have been shown in the athletic and prearthritic population in short-term and long-term follow-up. In the current study, the authors' hypothesis was that patients with a workers' compensation claim would have inferior outcomes after hip arthroscopy compared with patients without a workers' compensation claim. All patients with a workers' compensation claim who underwent hip arthroscopy over a 2-year period were studied. Postoperative functional outcomes were assessed with the Hip Outcome Score and modified Harris Hip Score. A cohort of 30 patients who did not have a workers' compensation claim was selected for comparison. Twenty-six patients were identified who had a workers' compensation claim and underwent hip arthroscopy performed by a single surgeon at the authors' institution with at least 6 months of follow-up. These patients were compared with 30 patients who did not have a workers' compensation claim. The workers' compensation group had a Hip Outcome Score of 66.5±28.8 and the non-workers' compensation group had a Hip Outcome Score of 89.4±12.0. This difference was statistically significant with Wilcoxon test (P=.003). The workers' compensation group had an average modified Harris Hip Score of 72.5±20.7 (mean±SD), and the non-workers' compensation group had a modified Harris Hip Score of 75.6±15.3. This difference was not significantly significant with Wilcoxon test (P=.9). At latest follow-up, 15 patients in the workers' compensation group (58%) were working. Patients returned to work an average of 6.8 months after surgery. The current study showed that postoperative functional outcomes in the workers' compensation group, as measured by Hip Outcome Score, were significantly inferior to those in the non-workers' compensation group. No statistical difference in postoperative modified Harris Hip Score was seen.

Billing and insurance-related administrative costs in United States' health care: synthesis of micro-costing evidence

BACKGROUND

The United States' multiple-payer health care system requires substantial effort and costs for administration, with billing and insurance-related (BIR) activities comprising a large but incompletely characterized proportion. A number of studies have quantified BIR costs for specific health care sectors, using micro-costing techniques. However, variation in the types of payers, providers, and BIR activities across studies complicates estimation of system-wide costs. Using a consistent and comprehensive definition of BIR (including both public and private payers, all providers, and all types of BIR activities), we synthesized and updated available micro-costing evidence in order to estimate total and added BIR costs for the U.S. health care system in 2012.

METHODS

We reviewed BIR micro-costing studies across healthcare sectors. For physician practices, hospitals, and insurers, we estimated the % BIR using existing research and publicly reported data, re-calculated to a standard and comprehensive definition of BIR where necessary. We found no data on % BIR in other health services or supplies settings, so extrapolated from known sectors. We calculated total BIR costs in each sector as the product of 2012 U.S. national health expenditures and the percentage of revenue used for BIR. We estimated "added" BIR costs by comparing total BIR costs in each sector to those observed in existing, simplified financing systems (Canada's single payer system for providers, and U.S. Medicare for insurers). Due to uncertainty in inputs, we performed sensitivity analyses.

RESULTS

BIR costs in the U.S. health care system totaled approximately $471 ($330 - $597) billion in 2012. This includes $70 ($54 - $76) billion in physician practices, $74 ($58 - $94) billion in hospitals, an estimated $94 ($47 - $141) billion in settings providing other health services and supplies, $198 ($154 - $233) billion in private insurers, and $35 ($17 - $52) billion in public insurers. Compared to simplified financing, $375 ($254 - $507) billion, or 80%, represents the added BIR costs of the current multi-payer system.

CONCLUSIONS

A simplified financing system in the U.S. could result in cost savings exceeding $350 billion annually, nearly 15% of health care spending.

Internal audits can safeguard hospital revenue

Hospitals should routinely perform internal audits of all functions affecting billing accuracy to mitigate the effects of payer audits and to protect revenue by improving billing processes. A primary focus for internal audits should be on coding accuracy, because coding errors leading to denials often reflect gaps in coders' knowledge or training. Effective communication between coding and denials management professionals is a critical success factor. Audits should support appeals processes, and audit findings should be used in educational initiatives aimed at improving coding accuracy.

Commentary: something has to give. the question is, what?

A large facet joint cyst, the size of a walnut, at L5-S1 resulted in an "emergency" laminectomy at Asheville, North Carolina's Mission Hospitals on this 79-year-old active equestrian and retired healthcare consultant, who more than a half-century earlier was formally trained in hospital administration and medical economics. While as an inpatient, he reflected broadly about today's healthcare expenditures, utilization, and quality, and speculated on possible future remedies.

Multi-faceted case management: reducing compensation costs of musculoskeletal work injuries in Australia

OBJECTIVES

This study aimed to determine whether a multi-faceted model of management of work related musculoskeletal disorders reduced compensation claim costs and days of compensation for injured workers.

METHODS

An intervention including early reporting, employee centred case management and removal of barriers to return to work was instituted in 16 selected companies with a combined remuneration over $337 million. Outcomes were evaluated by an administrative dataset from the Victorian WorkCover Authority database. A 'quasi experimental' pre-post design was employed with 492 matched companies without the intervention used as a control group and an average of 21 months of post-intervention follow-up. Primary outcomes were average number of days of compensation and average cost of claims. Secondary outcomes were total medical costs and weekly benefits paid.

RESULTS

Information on 3,312 claims was analysed. In companies where the intervention was introduced the average cost of claims was reduced from $6,019 to $3,913 (estimated difference $2,329, 95 % CI $1,318-$3,340) and the number of days of compensation decreased from 33.5 to 14.1 (HR 0.77, 95 % CI 0.67-0.88). Medical costs and weekly benefits costs were also lower after the intervention (p < 0.05). Reduction in claims costs were noted across industry types, injury location and most employer sizes.

CONCLUSIONS

The model of claims management investigated was effective in reducing the number of days of compensation, total claim costs, total medical costs and the amount paid in weekly benefits. Further research should investigate whether the intervention improves non-financial outcomes in the return to work process.

Cost of hospitalization and length of stay in people with Down syndrome: evidence from a national hospital discharge claims database

The present paper aims to describe the hospitalization profiles which include medical expenses and length of stays, and to determine their possible influencing factors of hospital admission on persons with Down syndrome in Taiwan. We employed a population-based, retrospective analyses used national health insurance hospital discharge data of the year 2005 in this study. Subject inclusion criteria included residents of Taiwan, and diagnosed with Down syndrome (ICD code is 758.0; N=375). Inpatient records included personal characteristics, admissions, length of stay, and medical expenses of study subjects. The results found that Down syndrome patients used 2 hospital admissions and their annual length of stay in hospital was 22.26 days, and the mean medical cost of admissions was 143,257 NT$. The admission figures show that Down syndrome individuals used two times of hospital days and nearly three times of medical expenses comparing to the general population in Taiwan. Finally, the multiple regression models revealed that factors of age, hold a serious illness card, low income family member, frequency of hospital admission, high medical expense user were more likely to use longer inpatient days (R2=0.36). Annual inpatient expense of people with Down syndrome was significantly affected by factors of severe illness card holder, low income family member, frequency of hospital admission and longer hospital stays (R2=0.288). Based on these findings, we suggest the further study should focus on the effects of medical problems among persons with Down syndrome admitted for hospital care is needed.

Diabetes prevalence based on health insurance claims: large differences between companies

AIMS

We investigated if there are substantial differences in the prevalence of diabetes between members of different health insurance funds in Germany and, if so, which variables might explain these differences.

METHODS

Ten representative surveys (conducted between 2004 and 2008) of the Bertelsmann Healthcare Monitor, comprising 15 089 participants aged 18-79 years, were analysed. Our main independent variable was membership in one of eight health insurance funds. We first estimated the crude prevalence of diabetes stratified by these funds. We further fitted logistic regression models and stepwise adjusted for age and sex, further co-morbidities and anthropometric measures and factors influencing health awareness and lifestyle.

RESULTS

The overall prevalence of diabetes was 6.9%. Stratified by health insurance funds, prevalences ranged between 3.9% within the Innungskrankenkassen to 11.4% within the Allgemeine Ortskrankenkassen. Adjusting for age and sex only led to minor changes. After controlling for all mentioned variables, these differences remained. Compared with those who were privately insured, persons within the Allgemeine Ortskrankenkassen (OR 1.73; 95% CI 1.30-2.29), the Betriebskrankenkassen (OR 1.54; 95% CI 1.15-2.07) and the Barmer (OR 1.39; 95% CI 1.01-1.91) had a higher prevalence.

CONCLUSIONS

We found considerable differences in diabetes prevalence between German health insurance funds that remained after controlling for several relevant variables.

Work-related asthma in health care in Ontario

BACKGROUND

The health of workers in health care has been neglected in the past. There are few reports regarding occupational asthma (OA) in this group, and work-exacerbated asthma (WEA) has rarely been considered.

METHODS

We examined the frequency of claims for OA and WEA allowed by the compensation board in Ontario, Canada for which industry was coded as "health care" between 1998 and 2002, to determine the frequency of OA and WEA, causative agents, and occupations.

RESULTS

During this period, five claims were allowed for sensitizer OA, two for natural rubber latex (NRL), and three for glutaraldehyde/photographic chemicals. The two NRL cases occurred in nurses who had worked for >10 years prior to "date of accident." There were 115 allowed claims for WEA; health care was the most frequent industry for WEA. Compared to the rest of the province, claims in health care made up a significantly greater proportion of WEA claims (17.8%) than OA (5.1%) (odds ratio, 4.1, 95% CI 1.6-11.6; P = 0.002). The rate of WEA claims was 2.1 times greater than that in the rest of the workforce (P < 0.0001). WEA claims occurred in many jobs (e.g., clerk), other than "classic" health care jobs such as nurses, and were attributed to a variety of agents such as construction dust, secondhand smoke, and paint fumes.

CONCLUSIONS

WEA occurs frequently in this industrial sector. Those affected and attributed agents include many not typically expected in health care. The incidence of OA claims in this sector in general was low; the continued low number of OA claims due to NRL is consistent with the successful interventions for prevention.

Evidence on the efficacy of inpatient spending on Medicare patients

CONTEXT

It is widely believed that a significant amount, perhaps as much as 20 to 30 percent, of health care spending in the United States is wasted, despite market forces such as managed care organizations and large, self-insured firms with a financial incentive to eliminate waste of this magnitude.

METHODS

This article uses Medicare claims data to study the association between inpatient spending and the thirty-day mortality of Medicare patients admitted to hospitals between 2001 and 2005 for surgery (general, orthopedic, vascular) and medical conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], stroke, and gastrointestinal bleeding).

FINDINGS

Estimates from the analysis indicated that except for AMI patients, a 10 percent increase in inpatient spending was associated with a decrease of between 3.1 and 11.3 percent in thirty-day mortality, depending on the type of patient.

CONCLUSIONS

Although some spending may be inefficient, the results suggest that the amount of waste is less than conventionally believed, at least for inpatient care.

In today's uncertain financial environment, how difficult will it be for you to collect on your disability insurance policy?

Disability insurance companies are in tough spot. The down economy, lack of profitability from the sale of new policies, and significant increase in the number of physician claims filed over the past several years have resulted in financial chaos. Many disability insurance companies are vanishing or feeling pressure to release reserves just to stay afloat, and unfortunately this materially affects claimants in the manner in which their claims are administered.

Costs by industry and diagnosis among musculoskeletal claims in a state workers compensation system: 1999-2004

BACKGROUND

Musculoskeletal disorders (MSDs) are a tremendous burden on industry in the United States. However, there is limited understanding of the unique issues relating to specific industry sectors, specifically the frequency and costs of different MSDs.

METHODS

Claim data from 1999 to 2004 from the Ohio Bureau of Workers' Compensation were analyzed as a function of industry sector (NAICS industry-sector categories) and anatomical region (ICD-9 codes).

RESULTS

Almost 50% of the claims were lumbar spine (26.9%) or hand/wrist (21.7%). The majority of claims were from manufacturing (25.1%) and service (32.8%) industries. The industries with the highest average costs per claim were transportation, warehouse, and utilities and construction. Across industries, the highest costs per claim were consistently for the lumbar spine, shoulder, and cervical spine body regions.

CONCLUSION

This study provides insight into the severity (i.e., medical and indemnity costs) of MSDs across multiple industries, providing data for prioritizing of resources for research and interventions.

Ergonomic and socioeconomic risk factors for hospital workers' compensation injury claims

BACKGROUND

Hospital workers are a diverse population with high rates of musculoskeletal disorders (MSDs). The risk of MSD leading to workers' compensation (WC) claims is likely to show a gradient by socioeconomic status (SES) that may be partly explained by working conditions.

METHODS

A single community hospital provided workforce demographics and WC claim records for 2003-2005. An ergonomic job exposure matrix (JEM) was developed for these healthcare jobs from direct observation of physical workload and extraction of physical and psychosocial job requirements from the O*NET online database. Occupational exposures and SES categories were assigned to workers through their O*NET job titles. Univariate and multivariate Poisson regression analyses were performed to estimate the propensity to file an injury claim in relation to individual factors, occupational exposures, and SES.

RESULTS

The jobs with the highest injury rates were nurses, semi-professionals, and semi-skilled. Increased physical work and psychological demands along with low job tenure were associated with an increase in risk, while risk decreased with psychosocial rewards and supervisor support. Both occupational and individual factors mediated the relationship between SES and rate of injury claims.

CONCLUSIONS

Physical and organizational features of these hospital jobs along with low job tenure predicted WC injury claim risk and explained a substantial proportion of the effects of SES. Further studies that include lifestyle risk factors and control for prior injuries and co-morbidities are warranted to strengthen the current study findings.

The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.