Discovering healthcare provider behavior patterns through the lens of Medicare excess charge

Abstract Background The phenomenon of excess charge, where a healthcare service provider bills Medicare beyond the limit allowed for a medical procedure, is quite common in the United States public healthcare system. For example, in 2014, healthcare providers charged an average of 3.27 times (and up to 528 times) the allowable limit for cataract surgery. Previous research contends that such excess charges may be indicative of the actual amount that providers bill to non-Medicare patients and subsequent cost-shifting behavior, where a healthcare provider tries to recoup underpayment by Medicare from privately insured, self-pay, out-of-network, and uninsured patients. Objectives The objective of this study is to examine the drivers of a provider’s excess charge patterns, especially the extent to which the degree of excess charges may be associated with physician characteristics, Medicare reimbursement policy, or socioeconomic status and demographics of a provider’s patient base. Methods Using data from the 2014 Medicare Provider Utilization files, we identify three procedures with the highest variation in Medicare reimbursements to study the excess charge phenomenon. We then employ a two-step cluster analysis within each procedure to identify distinct provider groups. Results Each procedure code yielded distinct healthcare provider segments with specific patient demographics and related behavior patterns. Cluster silhouette coefficients indicate that these segments are unique. Three random subsamples from each procedure establish the stability of the clusters. Conclusions For each of the three procedures investigated in this study, a sizeable number of healthcare providers serving poorer, riskier patients are often paid significantly lower than their peers, and subsequently have the highest excess charges. For some providers, excess charges reveal possible cost-shifting to private insurance. Patterns of excess charges also indicate an imbalance of market power, especially in areas with lower provider competition and access to health care, thus leading to urban-rural healthcare disparities. Our results reinforce the call for price transparency and an upper limit to overbilling.

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Motivational Application of Standardized Antimicrobial Administration Ratios Within a Healthcare System

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.918 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s321-s321

Author(s):

Stephanie Shealy ◽

Joseph Kohn ◽

Emily Yongue ◽

Casey Troficanto ◽

Brandon Bookstaver ◽

...

Keyword(s):

Patient Care ◽

Healthcare System ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Healthcare Providers ◽

The United States ◽

Antimicrobial Use ◽

Gram Positive ◽

Specific Patient ◽

Antimicrobial Administration

Background: Hospitals in the United States have been encouraged to report antimicrobial use (AU) to the CDC NHSN since 2011. Through the NHSN Antimicrobial Use Option module, health systems may compare standardized antimicrobial administration ratios (SAARs) across specific facilities, patient care locations, time periods, and antimicrobial categories. To date, participation in the NHSN Antimicrobial Use Option remains voluntary and the value of reporting antimicrobial use and receiving monthly SAARs to multihospital healthcare systems has not been clearly demonstrated. In this cohort study. we examined potential applications of SAAR within a healthcare system comprising multiple local hospitals. Methods: Three hospitals within Prisma Health-Midlands (hospitals A, B, and C) became participants in the NHSN Antimicrobial Use Option in July 2017. SAAR reports were presented initially in October 2017 and regularly (every 3–4 months) thereafter during interprofessional antimicrobial stewardship system-wide meetings until end of study in June 2019. Through interfacility comparisons and by analyzing SAAR categories in specific patient-care locations, primary healthcare providers and pharmacists were advised to incorporate results into focused antimicrobial stewardship initiatives within their facility. Specific alerts were designed to promote early de-escalation of antipseudomonal β-lactams and vancomycin. The Student t test was used to compare mean SAAR in the preintervention period (July through October 2017) to the postintervention period (November 2017 through June 2019) for all antimicrobials and specific categories and locations within each hospital. Results: During the preintervention period, mean SAAR for all antimicrobials in hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Notably, mean SAARs at hospitals A, B, and C in intensive care units (ICU) during the preintervention period were 0.67, 1.36, and 0.83 for broad-spectrum agents used for hospital-onset infections and 0.59, 1.27, and 0.68, respectively, for agents used for resistant gram-positive infections. After antimicrobial stewardship interventions, mean SAARs for all antimicrobials in hospital B decreased from 1.09 to 0.83 in the postintervention period (P < .001). Mean SAARs decreased from 1.36 to 0.81 for broad-spectrum agents used for hospital-onset infections and from 1.27 to 0.72 for agents used for resistant gram-positive infections in ICU at hospital B (P = .03 and P = .01, respectively). No significant changes were noted in hospitals A and C. Conclusions: Reporting AU to the CDC NHSN and the assessment of SAARs across hospitals in a healthcare system had motivational effects on antimicrobial stewardship practices. Enhancement and customization of antimicrobial stewardship interventions was associated with significant and sustained reductions in SAARs for all antimicrobials and specific antimicrobial categories at those locations.Funding: NoneDisclosures: None

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Breastfeeding Knowledge and Intent to Breastfeed

Clinical Lactation ◽

10.1891/2158-0782.7.2.62 ◽

2016 ◽

Vol 7 (2) ◽

pp. 62-68 ◽

Cited By ~ 2

Author(s):

Emily Lee ◽

Joanie Jackson

Keyword(s):

Healthcare Provider ◽

Healthcare Providers ◽

The United States ◽

Evidence Based ◽

Provider Education ◽

Breastfeeding Knowledge ◽

Self Confidence ◽

Breastfeeding Education ◽

Provider Knowledge ◽

Common Barriers

Objectives: Identify, synthesize, and critically review research on common barriers to successful breastfeeding and ways healthcare providers can assist patients in overcoming the barriers.Methods: A search of databases and citations for evidence-based research published from 2001 to 2015 was conducted. Forty-nine articles were reviewed with 22 articles being discussed.Results: Three major themes were identified: (a) characteristics of breastfeeding education in the prenatal setting, (b) primary care interventions to promote breastfeeding, and (c) healthcare provider education on breastfeeding.Conclusions: Findings of this review collectively suggest the need to increase breastfeeding rates among women in the United States. To achieve this, there is great significance placed on healthcare providers implementing interventions to promote breastfeeding, which subsequently requires improving healthcare provider knowledge and self-confidence on breastfeeding.

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From Experimental Procedure to Clinical Practice: How Much Evidence Do We Need in Uterine Transplantation?

10.20944/preprints201806.0420.v1 ◽

2018 ◽

Author(s):

Sabina Gainotti ◽

Carlo Petrini

Keyword(s):

Clinical Practice ◽

Therapeutic Option ◽

Clinical Care ◽

Embryo Implantation ◽

Healthcare Providers ◽

The United States ◽

Public Healthcare ◽

Routine Practice ◽

Functional Abnormality ◽

Experimental Procedure

Background: Absolute uterine factor infertility (AUFI) is a kind of infertility that is completely attributable to uterine absence (surgical or congenital for women with Mayer-Rokitansky-Küster-Hauser syndrome: MRKH) or anatomic or functional abnormality that prevents embryo implantation or completion of pregnancy to term. Until recently, the only viable option to parenthood for couples with AUFI were adoption or surrogacy. Since a first attempt of uterus transplant (UTx) in 2000, nine babies were born from women with a transplanted uterus from 2014, eight of which in Sweden, and one in the United States. These promising results are raising immense hopes for the women with AUFI and there is optimism about the possibility for UTx to become part of clinical care even though, besides encouraging results, the procedure has also resulted in increased risks and harms for both the donors and recipients and increased risks of premature birth for the fetus. At present UTx is still considered as experimental and requiring more research and safety assessment before becoming a therapeutic option for AUFI. The transition from experimental procedure to therapeutic care would result in less strict ethical scrutiny for UTx and in the possibility for patients to get reimbursement for the procedure by the relevant healthcare insurance or public healthcare providers. In turn, an increase in the number of UTx performed yearly by specialized surgical teams would result in a general improvement of the “field strength”. However, at present it is difficult to establish the amount of evidence that we need in order to consider UTx as no longer experimental but routine clinical practice. The literature on UTx provides recommendations on the different outcomes that should be monitored in this experimental phase but no study is anticipating the number of subjects that should be followed and for how long. Conclusion: As for other transplants that have become routine practice, like renal transplant and heart transplant, it is likely that the decision on “routine practice readiness” will result from available cumulated evidences, from expert capacity to find a consensus on best practices and on political considerations as well, including pressures form patients and patient groups.

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Unsubstantiated health claims for COVID-19 infections are led by cannabidiol: return of snake oil medicine

Journal of Cannabis Research ◽

10.1186/s42238-021-00109-6 ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Allan Tran ◽

Natasha Y. Sheikhan ◽

Tania Sheikhan ◽

Dominik A. Nowak ◽

Theodore J. Witek

Keyword(s):

Content Analysis ◽

Drug Evaluation ◽

Healthcare Providers ◽

Product Category ◽

Drug Approval ◽

The United States ◽

Therapeutic Benefit ◽

Health Claims ◽

Public Healthcare ◽

Related Substances

Abstract Background The United States Food and Drug Administration (FDA) monitors, inspects, and enforces the promotion of products by companies that claim to mitigate, prevent, treat, diagnose, or cure COVID-19. The introduction of COVID-19-related diagnostics and therapeutics during the pandemic has highlighted the significance of rigorous clinical trials to ensure safety and efficacy of such interventions. The objective of this report is to provide a descriptive review of promotional violations of health products for COVID-19 infection. Methods Warning letters issued by the FDA’s Center for Drug Evaluation and Research were retrieved over an 18 month period (March 6, 2020, to August 30, 2021) to identify promotional violations. FDA violation letters categorized as “Unapproved and Misbranded Products Related to Coronavirus Disease 2019 (COVID-19)” were reviewed. A content analysis was performed for each letter to identify categories for product type, promotional venue, violation type, and country of origin. For cannabidiol-related violations, a content analysis was repeated within its own product category. Results A total of 130 letters were reported. Across all letters, cannabidiol products were the most frequent subject of violation (15/130; 11.5%). Of the cannabidiol letters, all reported the promotion of unapproved products (15/15; 100%), misbranding (15/15; 100%), and/or had claims that lacked scientific substantiation (14/15; 93.3%). All promotional violations were linked to websites (15/15; 100%), along with other mainstream venues: Facebook, Instagram, YouTube, Twitter, LinkedIn, and email. Lastly, the cannabidiol products were described to provide therapeutic benefit to COVID-19, by acting as an anti-viral (5; 33.3%), pro-inflammatory (1; 6.7%), anti-inflammatory (7; 46.7%), immune-booster (5; 40%), immune-suppressor (2; 13.3%), and/or other (2; 13.3%). Conclusion Despite the urgent need for COVID-19 treatments, promotional material by companies must comply with standard regulatory requirements, namely substantiation of claims. As the pandemic persists, the FDA must continue their efforts to monitor, inspect, and enforce violative companies. Cannabidiol-related substances led the spectrum of products with unsubstantiated claims to treat COVID-19 infection. Improving awareness among the public, healthcare providers, and stakeholders highlights the value of drug approval process, while protecting public safety.

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Uncovering inefficiencies in the workers’ compensation industry using Lean methodology

The TQM Journal ◽

10.1108/tqm-06-2021-0163 ◽

2021 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Omar Taha ◽

Thomas A. Mazzuchi ◽

Shahram Sarkani ◽

Jiju Antony ◽

Sandra Furterer

Keyword(s):

Physical Therapy ◽

Case Studies ◽

Healthcare Provider ◽

Healthcare Providers ◽

Value Added ◽

The United States ◽

Injured Workers ◽

Insurance Companies ◽

Workers Compensation ◽

Content Type

PurposeThe purpose of this paper is to apply Lean in the workers’ compensation industry. It focuses on identifying patterns of repetitive non-value-added transnational activities for physical-therapy patients and healthcare providers. It addresses the research gap in this field.Design/methodology/approachIn this study, we designed and deployed multiple case studies to better understand the journey of an injured worker within the worker compensation system in the United States of America. We partnered with Concentra Inc., a leading national healthcare provider in the field of workers’ compensation having 520 medical centers in 44 states. Both case studies included conducting direct observations, Gemba walk, in five clinics in two states: Florida and Pennsylvania. We analyzed the data of 263 injured workers with 8 or more physical therapy visits who got admitted to Concentra clinics in both states over the period of 31 days.FindingsThe results revealed that the time intervals at which activities associated with physical therapy treatment pre-authorization accounted for 91.59% of the total non-value-added activities and are thus the key administrative factor leading to process inefficiency in the state of Florida. The Process Cycle Efficiency of Pennsylvania was 75.36% compared to 53.16% of Florida. The injured workers in Florida needed 39.58 days on average to complete eight physical therapy visits compared to 27.92 days in Pennsylvania (a median of 34.09 vs 22.15 days).Research limitations/implicationsThis study is limited as it only focuses on processes on the healthcare provider side. An expanded value stream map that includes the treatment pre-authorization process on the insurance side would be beneficial for generating more potential solutions to streamline the process.Practical implicationsThis study shows that Lean could play a critical role in identifying and quantifying continuous improvement opportunities that could accelerate patient’s treatment, reduce administrative burden on healthcare providers and improve the overall claim cost of insurance companies. It provides data-driven argument for insurance companies to consider eliminating physical therapy pre-authorization.Originality/valueThis is the first study to apply Lean methodology in the workers’ compensation field.

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Family-healthcare Provider Communication and Reported Health among Children and Adolescents in the United States

Californian Journal of Health Promotion ◽

10.32398/cjhp.v15i1.1888 ◽

2017 ◽

Vol 15 (1) ◽

pp. 46-55

Author(s):

Gergana D. Kodjebacheva ◽

Leobardo F. Estrada ◽

Shan Parker

Keyword(s):

Healthcare Provider ◽

Healthcare Providers ◽

The United States ◽

Children's Health ◽

Children’S Health ◽

Activity Limitations ◽

Provider Communication ◽

Health Coverage ◽

Reported Health ◽

Healthcare Communication

Background and Purpose: Most research regarding healthcare communication focuses on adults. The study investigated how family-healthcare provider communication influences reported health and activity limitations among U.S. children ages 0 to 17. Methods: In the 2011-2012 National Survey of Children’s Health, parents reported information on 87,133 children aged 0 to 17 years. The influences of different aspects of perceived healthcare communication on reported health and activity limitations were assessed using weighted logistic regression. Results: Children who were Hispanic or non-Hispanic Black, spoke a language other than English, had unemployed parents, and received public health coverage tended to have healthcare providers who did not communicate effectively. Hispanics reported worse communication experiences than non-Hispanic Blacks. Children whose provider never/sometimes spent enough time with them were more likely to have poor/fair health and to have activity limitations compared to those whose provider usually/always spent enough time. Having a healthcare provider who reportedly never/sometimes listened carefully to the caregiver was associated with poor/fair health and activity limitations (among children. Conclusion: Ineffective communication between healthcare providers and families was associated with poor reported health. Ineffective communication was more commonly reported by non-Hispanic Black and Hispanic families compared to non-Hispanic White families. Interventions to improve communication may promote children’s health.

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All-Payer Rate Setting: A Framework for a More Efficient Health Care System

Policy Perspectives ◽

10.4079/pp.v24i0.17604 ◽

2017 ◽

Vol 24 ◽

pp. 81

Author(s):

Eric Flanagan

Keyword(s):

Health Care ◽

Health Care System ◽

Health Care Services ◽

Health Care Systems ◽

Private Insurance ◽

The United States ◽

Insurance Companies ◽

Cost Shifting ◽

The Us ◽

Care System

The United States is unique among countries with health care systems that rely primarily on private insurance companies because there are generally no regulations that mandate a standard fee schedule for health care services. The prevalence of multiple private and public insurers is known as a multi-payer system. Other countries that have multiple payers set prices unilaterally, as is the case in Japan, or through negotiations between payers and providers, as is the case in Germany. The outcome is a uniform set of prices that applies to all payers within a single hospital. This framework is known as all-payer rate setting. This paper explains how all-payer rate setting regulation can mitigate several problems plaguing the US health care system. Examples include cost shifting, price discrimination, and provider market leverage. The paper then analyzes how these problems negatively affect the US health care system. Finally, the benefits of all-payer rate setting are explained, followed by the downsides (or tradeoffs) of such a system.

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Latino Fathers Report Low Awareness and Knowledge of the Human Papillomavirus Vaccine, but High Willingness to Vaccinate Their Children if Recommended by Primary Healthcare Provider: a Qualitative Study

10.20944/preprints202012.0525.v1 ◽

2020 ◽

Author(s):

Ana Cristina Lindsay ◽

Denisse Delgado ◽

Madelyne J. Valdez ◽

Phillip Granberry

Keyword(s):

United States ◽

Qualitative Study ◽

Healthcare Provider ◽

Primary Healthcare ◽

Hpv Vaccine ◽

Critical Role ◽

Healthcare Providers ◽

The United States ◽

Future Research ◽

Primary Healthcare Provider

Objective: Despite increasing interest in understanding factors influencing awareness, knowledge, and acceptability of the human papilloma virus (HPV) vaccine among Latino parents to date, limited information is available specific to Latino fathers living in the United States. Methods: This descriptive qualitative study explored Latino fathers’ awareness, knowledge, and acceptability of the HPV vaccine for their adolescent children. Data were collected through individual, semi-structured interviews and analyzed using a hybrid method of thematic analysis that incorporated deductive and inductive approaches. Results: Nineteen, majority foreign-born Latino fathers (63.2%; n = 12) fathers of male and female adolescents participated in the study. Four main themes and two subthemes emerged from the analyses. Results found fathers’ low awareness and knowledge of HPV and the HPV vaccine. Results also identified fathers’ positive attitude toward vaccines in general. Moreover, results revealed fathers’ trust in healthcare providers. This trust translated into an increased willingness to vaccinate their children against HPV if recommended by their child’s primary healthcare provider. Conclusion: Findings indicate the need for increased efforts to raise awareness and knowledge among Latino fathers of HPV and the HPV vaccine. In addition, findings underscore the critical role of healthcare providers’ recommendation of the HPV vaccine. Given the limited research focused on Latino fathers, this study’s findings are valuable in building a knowledge foundation needed for developing future studies and interventions to promote the HPV vaccine by targeting Latino fathers living in the United States. Future research should quantify Latino fathers' awareness, knowledge, and acceptability of the HPV vaccine for their children, and preferences for educational interventions to promote HPV vaccination.

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Knowledge and Communication of the National Core Standards Tool

Africa Journal of Nursing and Midwifery ◽

10.25159/2520-5293/3659 ◽

2018 ◽

Vol 20 (2) ◽

Author(s):

Winnie Thembisile Maphumulo ◽

Busisiwe Bhengu

Keyword(s):

Pearson Correlation ◽

Healthcare Delivery ◽

Healthcare Providers ◽

Sampling Technique ◽

Quality Of Healthcare ◽

Survey Study ◽

Public Healthcare ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Professional Nurses

The National Department of Health in South Africa has introduced the National Core Standards (NCS) tool to improve the quality of healthcare delivery in all public healthcare institutions. Knowledge of the NCS tool is essential among healthcare providers. This study investigated the level of knowledge on NCS and how the NCS tool was communicated among professional nurses. This was a cross-sectional survey study. Purposive sampling technique was used to select hospitals that only offered tertiary services in KwaZulu-Natal. Six strata of departments were selected using simple stratified sampling. The population of professional nurses in the selected hospitals was 3 050. Systematic random sampling was used to recruit 543 participants. The collected data were analysed using SPSS version 25. The study showed that only 16 (3.7%) respondents had knowledge about NCS, using McDonald’s standard of learning outcome measured criteria regarding the NCS tool. The Pearson correlation coefficient between the communication and knowledge was r = 0.055. The results revealed that although the communication scores for the respondents were high their knowledge scores remained low. This study concluded that there is a lack of knowledge regarding the NCS tool and therefore healthcare institutions need to commit themselves to the training of professional nurses regarding the NCS tool. The findings suggest that healthcare institutions implement the allocation of incentives for nurses that attend the workshops for NCS.

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Capturing the surge of public interest towards Hydroxychloroquine, Azithromycin and BCG vaccine during COVID-19 Pandemic (Preprint)

10.2196/preprints.19482 ◽

2020 ◽

Author(s):

Shabbir Syed-Abdul ◽

Shwetambara Malwade ◽

Sim-Mei Choo

Keyword(s):

Social Media ◽

Preventive Measures ◽

Healthcare Providers ◽

Specific Treatment ◽

Drug Effects ◽

The United States ◽

Bcg Vaccine ◽

Public Interests ◽

Treatment Regimes ◽

Appropriate Treatment

UNSTRUCTURED The outbreak of COVID-19 that started in December 2019, was declared a pandemic in March 2020. Currently, there is no specific treatment recommended and healthcare providers are struggling to find appropriate treatment regimes. Medication misinformation spread through social media has caused panic situations and self-prescription leading to harmful drug effects. The situation worsened following false propaganda via social media, leading to shortage of some medications. Our study shows the frequency of search for the medications Hydroxychloroquine (HCQ), Azithromycin and Bacillus Calmette-Guérin (BCG) vaccine in Google Trends, across 6 countries. Public interests from the United States, Italy and Spain leaned towards HCQ, whereas those from Taiwan, Japan and South Korea were keen towards learning about the BCG vaccine. Our article aimed to inform the general public of the adverse drug reactions to avoid self-prescription or yield to the assumptions of leaders and unanimous social media posts. Proactive participation and preventive measures such as social distancing, use of face masks and hand sanitizers are recommended to help curb COVID-19 and other infections.

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