For much of the early 1960s, House Ways and Means chairman Wilbur Mills represented the “One-Man Veto” on Medicare before eventually offering his reluctant support to the measure in 1964 and 1965. Ironically, this longtime opponent would be the one to suggest an expansion in the scope of the bill. Early proposals for Medicare only offered to cover hospital costs; Mills would call for physician costs to be covered, as well. The aim of this thesis is to show how Mills’s expansion of Medicare benefits in 1965 caused health care costs to skyrocket in the late 1960s, causing the fiscally conservative Mills to co-sponsor legislation for a single-payer national health insurance program along with Senator Edward Kennedy almost a decade later.

Magister Scientiae - MSc / The aim of this study was to examine the extent to which providers' practices affect the cost of hospital procedures incurred by patients. The spsecific objective was to explore the magnitude of variations and statistically establish the significance of relationships between admission/specialist costs incurred by patients for four major procedures and the hospital group, geographical location, employer group and demmographic realted risk profiles. The study contributes to a better understanding of the way in which managed care companies could channel beneficiaries of medical schemes to efficient providers. / South Africa

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23758号 / 医博第4804号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 川上 浩司, 教授 小濱 和貴 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Increase in the cost of medical care services has become an important issue in many countries that have implemented national health insurance, including Taiwan. On July of 2002, the National Health Insurance of Taiwan implemented a global budgeting system for all hospital payments. It was hoped that such a system would control the increase of medical expenses within a certain expected range. However, in the absence of reasonable payment bases and effective utilization management and control mechanism, the outcome of implementing this new payment system has been difficult to measure. Therefore, the National Health Insurance (NHI) studied the possibility of implementing DRGs (diagnosis related groups) for all in-patient payments. To evaluate the impact of the new payment system, the medicinal datas collected 1 year before and after implementation of TW-DRGs were analyzed. The tested target is an orthopaedic department in a Public Medical Center. The tested items including average of days in hospital, medical costs, application of National insurance, and sub-item total knee replacement (TKR) and total hip replacement (THR). For overall investigation of the tested orthopaedic department, our findings revealed that implementation of TW-DRGs significantly diminished the average of days in hospital and the average of medical costs. However, implementation of TW-DRGs showed slight influence on the National Health Insurance Application. As to investigate common surgeries, TKR and THR, only the average of days in hospital of TKR was significantly decreased by implementation of TW-DRGs. In addition, other specific TW-DRGs numbered items were also examined to determine the alteration of the factors described above. Our results showed that implementation of TW-DRGs significantly diminished the days in hospital, the medical cost, and the National Health Insurance Application for the selected TW-DRGs numbered items. However, the quality in health care didn¡¦t have significant change after implementation of TW-DRGs. More complete data pools are needed for the more precise analysis to evaluate the influence of TW-DRGs system on the management of hospital and other medical factors in Taiwan.

Back pain is the 6th most costly condition in the United States and is responsible for the most workdays lost. Approximately 33 million American adults suffered from back and neck problems in 2005. The societal cost of chronic back pain (CBP) has not been calculated from a US perspective. Longitudinal data files from Panels 12, 13, and 14 of the Medical Expenditure Panel Survey (MEPS) were used to estimate excess direct (ambulatory visits, inpatient admissions, emergency room visits, and prescription medication) costs and indirect (lost productivity) costs for persons 18 years and older reporting CBP compared to those not reporting back pain. Persons were included in the CBP group if they reported back pain (ICD-9-CM codes 720, 721, 722, 723, 724, 737, 805, 806, 839, 846, 847) in at least 3 consecutive interview rounds. The complex sampling design of MEPS was taken into account to get accurate national estimates. All costs were adjusted to 2011 using Consumer Price Indices. All mean costs were computed using age-stratified regression models, after adjusting for demographic and clinical covariates. Utilization of provider-based complementary and alternative medicine (CAM) among CBP patients was studied, and differences in costs between CAM users and non-users examined. Based on this analysis, the prevalence of CBP in the adult US population was estimated to be 3.76%. Total all-cause costs for CBP patients were estimated to be $187 billion over 2 years (direct costs = $176 billion, indirect cost = $11 billion). Overall estimates of excess costs of CBP over 2 years per person for direct medical costs were $37,129 ($25,273 vs. $48,984; p<0.001). This breaks down to $11,711 ($14,929 vs. $3,219; p<0.001) for ambulatory visits; $3,560 ($6,514 vs. $2,914; p<0.001) for inpatient admissions; $300 ($690 vs. $390; p<0.001) for emergency department visits; and $19,849 ($23,873 vs. $4,024; p<0.001) for prescription medications. Excess indirect costs for CBP patients were $1,668 ($2,329 vs. $661; p<0.001). Thirty-seven percent of CBP patients reported at least one CAM visit. There was no significant difference in overall costs between CAM users and non-users. The high cost of chronic back pain in the US population has potential implications for prioritizing policy, and in attempting to improve care and outcomes for these patients. / text

Made available in DSpace on 2015-07-22T20:49:49Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-11-26 / A esquizofrenia apresenta elevado custo de doença e a recaída é um dos seus aspectos mais importantes. OBJETIVO: Avaliar o Custo Direto Médico- Hospitalar da recaída em esquizofrenia, em três diferentes serviços de admissão em saúde mental na cidade de São Paulo utilizados por pacientes quando da reagudização da doença: a) um hospital público estadual (HP); b) um hospital contratado conveniado com o SUS (HCC); e c) um Centro de Atenção Psicossocial (CAPS). METODOLOGIA: Foram revisados 90 prontuários de pacientes portadores de esquizofrenia atendidos durante o ano de 2006 em internação hospitalar ou atendimento intensivo no CAPS. Foram levantados e valorados os recursos utilizados durante a permanência nos serviços: medicação, exames e diárias – onde foram incluídos os custos com recursos humanos. RESULTADOS: o Custo Direto Médico-Hospitalar médio da recaída em esquizofrenia, por paciente foi de R{dollar} 8.167,58 no HP; R{dollar} 4.605,46 no CAPS e de R{dollar} 2.397,74 no HCC sendo o principal componente, o custo com diárias, a maior delas no HP. O custo com medicação diferiu quanto à utilização de antipsicóticos típicos ou atípicos, sendo os típicos mais utilizados no HCC e os atípicos no CAPS. Nos três serviços poucos exames complementares foram realizados. CONCLUSÃO: O investimento em medicações antipsicóticas e em estratégias que diminuam a recaída e a necessidade de diárias nos serviços, especialmente hospitalares, são justificáveis pela proporção dos custos que estas representam. O maior custo ocorreu no HP e o menor custo no HCC. Tratar a recaída no CAPS apresentou um custo intermediário com o benefício de não privar o paciente do convívio familiar, usando medicação com menor potencial de efeitos adversos e com impacto positivo na qualidade de vida dos pacientes. / Aims: Significant cost is associated with schizophrenia and relapses are one significant cost element. Objective: Assess the direct medical costs associated with schizophrenia relapses at three mental health services in the city of São Paulo: a public state hospital (HP); a hospital affiliated with the Brazilian Unified Healthcare System -SUS (HCC); a Community Psychosocial Service Center (CAPS). Methods: We reviewed the charts of 90 patients with schizophrenia who had been i n services in 2006. We evaluated the r esources used dur ing the time these patients were in services. Results: The Mean Direct Medical Cost of schizophrenia relapses was, per patient, R{dollar} 8.167,58 i n HP; R{dollar} 4.605,46 at the CAPS and R{dollar} 2.397,74 in HCC ( R{dollar} 2 / 1 US{dollar}). The most significant component in all cases was the daily rate. The cost of medication differed depending on whether typical or atypical antipsychotics were used. CAPS making more use of atypical drugs. Conclusion: The costs associated with schizophrenia relapses justify investments in antipsychotic drugs and strategies to reduce the need for mental health services, especially hospitals. The cost associated with treating patients in a CAPS is intermediate and has the added benefit of not depriving patients from their family life. / TEDE / BV UNIFESP: Teses e dissertações

Purpose: Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization. Methods: Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural. Findings: The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization. Conclusions: Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.

Back pain is one of the most expensive medical conditions to treat. There has been a great deal of research showing that back pain surgery is expensive, but less is known about the costs of less-invasive spine procedures such as radiofrequency neurotomy. Radiofrequency neurotomy is used to treat facet joint pain and typically offers temporary pain relief by coagulating the affected nerve with radiofrequency waves to block pain messages from reaching the brain. This study aimed to document the costs of radiofrequency neurotomy in a group of participants who received the procedure through the Workers’ Compensation Fund of Utah (WCFU). Another goal of the study was to determine if any biopsychosocial variables of participants predicted costs. Biopsychosocial variables include biological (e.g., age), psychological (e.g., depression), and social (e.g., hiring a lawyer) characteristics about participants. Costs and characteristics were collected from participant medical records. Compensation and medical costs were collected; compensation costs were wage payouts as a result of an on-the-job injury, and medical costs were direct medical costs. Both compensation and medical costs were substantial and similar to other more invasive procedures. Furthermore, three biopsychosocial characteristics predicted high costs. A high number of prior back and neck surgery and lawyer involvement predicted high compensation costs. Those same variables plus history of depression predicted high medical costs. This was the first known study to document medical and compensation costs associated with spinal radiofrequency neurotomy. The findings add to the line of research suggesting that a biopsychosocial framework can be used to predict costs in spine care. Discovering participant characteristics that may predict high costs can inform policylevel decisions for insurers, and can be used by medical providers to influence patient care decisions. More research on the presurgical variables may lead to interventions at the patient level that can reduce high cost outcomes which could benefit both patients and payers.

No description available.

Hepatocellular carcinoma (HCC) is the second most common cancer in Taiwan and transcatheter arterial chemoembolization (TACE) is now the mainstay of treatment for noncurative HCC. Due to increasing medical costs yearly and financial problem of the Bureau of National Health Insurance, it is important to reduce medical resource utilization including hospital stay and medical costs. The aim is to figure out the risk factors of extended hospital stay, and increased in-hospital medical costs in hepatocellular carcinoma patients receiving transcatheter arterial chemoembolization. The result of this study should be available for further improvement of medical care quality in the limited medical resource. From January 2008 to January 2010, 162 patients (121 male and 41 female) with histologically proven hepatocellular carcinoma underwent TACE only (131 pts) or TACE followed by catheter placement for hepatic artery infusion chemotherapy (HAIC) (31pts) at district teaching hospital. The extended hospital stay (EHS) and extended post-procedure stay (EPS) are defined as stay larger than their median values (11 & 7 days respectively). Clinical demographic, disease factors, tumor factors, procedure (TACE)-related factors and complications are used to identify the univariate factors related to EHS and EPS statistically. To find out predictors of EHS, EPS and increased in-hospital medical costs, multiple linear regression analyses are used. The risk factors for EPS are procedure-related, including complications and procedure methods ( TACE + HAIC related to TACE only) (R2=.367, p<.001), while those for EHS are complications, encephalopathy, procedure methods, Child-Pugh classification C (related to classification A) and age (R2=.490, p<.001). The predictors for increased in-hospital medical costs include procedure methods, AJCC stage IV, T4 stage, hepatoencephalopathy and complications (R2=0.615, p<.001). Taking total hospital stay into consideration, the most important risk factor related to increased medical cost is total hosptial stay itself. The most powerful risk factor for EPS, EHS is procedure-related complication. The different procedure methods also affect hospital stay and medical costs. In order to reduce medical resource utilization, we should avoid post-procedure complication and pay attention to cirrhotic degree as well as American Joint Committee of Cancer (AJCC) tumor stage system. The result of this study can provide some ideas to adjust medical expense polices for the Bureau of National Health Insurance and to control medical cost for the hospitals.