Health Care Economics


The Impact of Utilization Management on Readmissions Among Patients with Cardiovascular Disease

Essay 3

“The Impact of Utilization Management on Readmissions Among Patients with Cardiovascular Disease” Daniel S. Lessler & Thomas M. Wickizer (HSR: Health Services Research 34:6 Feb. 2000)

This article discusses the impact that utilization management on readmission of cardiovascular disease patients within 60 days. Despite widespread use of utilization management, surprisingly little is known about its effects on patterns of care. In medical admissions whose length of stay (LOS) was reduced by utilization management, there was no significant incidence of readmission. In surgical admissions whose LOS was reduced by utilization management, there were a significant number of readmissions within 60 days.

Economic concepts used in this article are utilization management, cost containment, managed care, hospitalization utilization, quality of care.

This impacts health care today because as utilization reviews cuts LOS it is increasing the need for readmission within 60 days in surgical patients. This could lead to increased costs in the second visit or repetition of several of the same events. It is difficult to tell if the second admission would have been avoided by a lengthier initial admission.


Outcomes of Stroke Patients in Medicare Fee for Service and Managed Care

Essay 4

Retchin, Sheldon M., Brown, Randall S., Yeh, Shu-Chuan Jennifer, Chu, Dexter, Moreno, Loreno “Outcomes of Stroke Patients in Medicare Fee for Service and Managed Care.” Journal of the American Medical Association. July 9, 1997. Vol 278, No. 2.

Data was collected and analyzed for stroke patients in Medicare fee for service and managed care plans. Outcomes measured were death, discharge and discharge status. Conclusions were Health Maintenance Organization patients were more likely to be discharged to nursing homes and less likely to go to rehabilitation centers after an acute cerebrovascular accident. The differences between Health Maintenance Organization and Fee For Service in the risk of dying for those without DNR orders after adjusting for variables were not significant. Ineligible cases were slightly higher in Health Maintenance Organization samples compared with Fee For Service samples. The Fee For Service patients had a higher prevalence of myocardial infarction within the 4 months prior to admission. No significance difference was found between the two groups with regards to history of atrial fibrillation or flutter, stroke, CVA, or transient ischemic attack, previous 6 months hospitalization, cancer, diabetes mellitus, chronic pulmonary disease, hypertension, and angina.

The two main types of insurance popular today are discussed as Health Maintenance Organizations restricts on payment for patient care. Payment restrictions can affect quality of care. Reduced quality of care can lead to more expensive longer recovery.


Health Care Economics Homework

Homework 6

Q1. What is SAV phenomenon? What are some economic forces that can help explain SAV? What are some demographic and other considerations? How might physician uncertainty lead to SAV? What evidence supports the practice style hypothesis?

Small area variations are the wide variations in the per capita utilization rates for many medical/surgical procedures that are commonly found in comparing small, contiguous hospital service markets. Low-income areas would promote underutilization. Some areas tend to lead to certain health problems, i.e. allergy, sinus, histoplasmosis, etc would tend to over utilize.

Physician uncertainty could lead to over utilization or underutilization. Practice guidelines, practice style evaluation, education, feedback and surveillance programs effect practice styles.

Q3. What possible criticisms can you propose for the idea that areas with high utilization rates for a procedure indicated the provision of unnecessary care?

Other areas may be underutilizing the procedure.

Q7. If one cause of SAV is lack of information about various procedures, would you expect SAV to have increased, decreased, or stayed the same over time? Why?

SAV would be expected to increase, decrease or stay the same depending on what was occurring within the area. If new physicians are entering the area and/or continuing education is occurring at an appropriate rate, I expect SAV to decrease. If continuing education is occurring but only enough to keep from falling behind, then SAV would stay the same. If continuing education & lack of new physicians occurs, then SAV would increase.

HomeworkVIII

Chapter 17

Q1. Explain why it is often claimed that hospitals compete for doctors rather than patients. What are some of the implications of this phenomenon assuming that it is true?

Patients usually listen to their physician as to which hospital to go to. Physicians usually have admitting privileges at several hospitals and they direct resources for patient care while hospitalized.

Q2. Even not-for-profit hospitals must earn a Òprofit.Ó Evaluate this statement.

Not-for-profit hospitals must make enough of a profit on patients who can pay to cover the costs of those who cannot pay. Also the hospital must cover overhead costs and technical upgrades.

Q6. Hospital costs have grown following growth of private and public insurance. Describe other factors that could account for some of the growth.

More expensive advanced medical technologies and fewer days of patient stay mean that hospitals have higher costs to cover with less money.