The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee‐for‐service settings. Design. Cross‐sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist‐immunologists, family practitioners, and from a random sample of the non‐institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee‐for‐service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta‐agonists, home nebulized beta‐agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI ? 5.4, ? 0.1), principally because those in MC had many fewer visits to allergist‐immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = ? 16.5, 95% CI ? 27.8–5.3). The two groups did not differ significantly in the proportion with asthma‐related or non asthma hospital admissions. Conclusions. Persons with asthma in fee‐for‐service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist‐immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

中医辩证论治价格项目增设的重要意义及实施建议

以中医辨证论治的内涵和学术特点为切入点,阐述了2012年版《全国医疗服务价格项目规范》中有关中医辨证论治项目的设立背景和重要意义,并提出了中医辨证论治项目实施的相关建议.     

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology

PurposeTo assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice.Materials and MethodsBilling and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures—(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement—were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals).ResultsDepartmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%.ConclusionsDepartmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.     

农村社区免费和自费治疗原发性高血压效果对比

目的对社区免费和自费治疗原发性高血压的效果进行比较,探讨农村社区高血压防治模式。方法将东海县农村社区经调查确诊的原发性性高血压患者分为2组,每组各150人,由经过培训的社区医生进行规范化管理(健康教育、行为干预、药物治疗和定期随访等)。一组免费给予基本的治疗药物,另一组自费使用同样的治疗药物,半年后比较两者的治疗效果。结果免费组规范化管理后平均收缩压和舒张压分别降低了19.49和12.75mmHg,血压控制率由管理前的3.33%上升至87.41%;自费组规范化管理后平均收缩压和舒张压分别降低了15.86和8.37mmHg,血压控制率由管理前的2.67%上升至39.33%,2组控制率差别有显著性差异(χ2=72.44,P<0.01)。结论针对农村经济条件较差、文化素质相对较低的特点,社区规范化管理能有效改变高血压患者不良生活方式,若由政府买单提供治疗药物,能更加提高治疗的依从性和控制率,是防治高血压的一种行之有效的方法。     

医疗保险基金支付方式改革对医疗质量的影响分析

探讨支付方式改革在医疗质量提升及医疗费用控制中的作用,以成都市门诊特殊疾病血液透析（门特血透）为例,分析了支付方式改革的必要性。目前,门特血透支付方式已从传统按项目付费过渡到按病种定额付费,以2014年成都市内两家收治患者情况类似的三级医院为例,模拟门特血透支付方式改革后的医院运行情况。探讨支付方式的改革可以间接督促医院医疗质量的提升和服务效率的提高。应在广泛准确收集数据的基础上,根据门特血透质效评价结果对医疗机构实行按医疗质量付费。     

控费政策对医院医疗业务收入及费用结构的影响研究

目的 研究控费政策对医院医疗业务收入和费用结构的影响,为完善新一轮控费政策提供依据.方法 通过间断时间序列、结构变动度等方法,比较控费政策实施前后医院医疗业务收入和费用结构指标的变化.结果 经模型检验,控费政策对医疗总收入、门诊次均费用、住院次均费用控制的即时效应显著,但尚未出现长期下降趋势;2018年下半年医院药占比...     

福建省2008年新农合131万住院病例基本规律研究

[目的]研究福建省2008年新型农村合作医疗（NCMS）131万人次住院病例的有关规律,以及高额住院费用的影响因素。[方法]收集全省2008年76个县市区131万个住院病例数据库（含27项指标）并分析有关规律,用SPSS软件包以logistic回归和ROC曲线,研究产生高额住院费（万元以上）的影响因素。[结果]乡、县、县外的病例数分别占42．7％、33．6％和23．7％,次均住院费为3904元,实际补偿比33．0％,次均补偿额1289元,次均住院9．5d,不可报销费用占比26．8％。导致高额住院费用的主要因素是“到县外住院”、“住院天数多”和“不可报销费用占比高”。[结论]加强县内医院建设,力争“小病不出乡,大病不出县”、尽量缩短住院天数,控制范围外费用占比,是控制高额住院费用的重点措施。     

美国处方药付费法案的演变特点及对我国新药审评的启示

目的：为完善我国新药审评制度提供参考。方法：分析美国《处方药付费法案》各阶段侧重点、监管措施及实施成效，进而针对我国新药审评实际提出相关建议。结果：PDUFA在显著缩短新药审评时间、改善研制效率、提高首轮审评通过率和助力极具创新性药物产出方面发挥了重要作用。结论：建议我国在确保药品安全有效前提下，通过加强新药研发指导、优化上市申请审评过程管理以及加快药品监管科学发展与应用等进一步完善新药审评制度。