Identifying Potential Care Management Candidates: The Use of Diagnosis-Based Models to Predict 5-Year Health Care Costs

2016 ◽  
Vol 17 (2) ◽  
pp. 105-111
Author(s):  
John Robst
Keyword(s):  
Health Care ◽  
Case Management ◽  
Regression Models ◽  
Care Management ◽  
Predictive Power ◽  
Service Use ◽  
Claims Data ◽  
Individual Characteristics ◽  
Estimation And Prediction ◽  
Care Costs

Objective: This article examined individual characteristics associated with having higher costs in a 5-year period to identify patients that may potentially benefit from case management.Methods: Florida Medicaid claims data from 2005 to 2010 were used to examine the characteristics, diagnoses, and services (in 2005) associated with individual costs in 5 future years (2006–2010). The data were divided into estimation and prediction samples with regression models estimated using diagnoses and service use in 2005 to predict future costs. Predictive power was assessed by applying the model results to the prediction sample and comparing predicted costs to actual costs.Results: Demographics, service use, and diagnosis in 2005 were associated with costs in the following 5 years. Models were predictive of future costs with a significant relationship between the predicted costs and actual costs.Conclusion: Diagnosis-based models in conjunction with prior costs can predict future costs. Individuals predicted to have higher costs may be candidates for case management to potentially avoid reduce costs.

scholarly journals Analgesic Usage for Low Back Pain: Impact on Health Care Costs and Service Use

Spine ◽  
2005 ◽  
Vol 30 (9) ◽  
pp. 1075-1081 ◽  
Author(s):  
Molly T. Vogt ◽  
C Kent Kwoh ◽  
Doris K. Cope ◽  
Thaddeus A. Osial ◽  
Michael Culyba ◽  
...  
Keyword(s):  
Health Care ◽  
Low Back Pain ◽  
Back Pain ◽  
Health Care Costs ◽  
Service Use ◽  
Low Back ◽  
Care Costs

Profiling Primary Care Physicians for a New Managed Care Network

1997 ◽  
Vol 10 (3) ◽  
pp. 173-186 ◽  
Author(s):  
R. J. Ozminkowski ◽  
M. Noether ◽  
P. Nathanson ◽  
K. M. Smith ◽  
B. E. Raney ◽  
...  
Keyword(s):  
Health Care ◽  
Primary Care Physicians ◽  
Claims Data ◽  
Severity Of Illness ◽  
Policy Implications ◽  
Case Mix ◽  
Reform Strategies ◽  
Insurance Program ◽  
Insurance Claims Data ◽  
Care Costs

We developed methods for comparing physicians who would be selected to participate in a major employer's self-insurance program. These methods used insurance claims data to identify and profile physicians according to deviations from prevailing practice and outcome patterns, after considering differences in case-mix and severity of illness among the patients treated by those providers. The discussion notes the usefulness and limitations of claims data for this and other purposes. We also comment on policy implications and the relationships between our methods and health care reform strategies designed to influence overall health care costs.

scholarly journals Outpatient health care utilization and health expenditures of asylum seekers in Halle (Saale), Germany - an analysis of claims data

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Andreas Niedermaier ◽  
Anna Freiberg ◽  
Daniel Tiller ◽  
Andreas Wienke ◽  
Amand Führer
Keyword(s):  
Health Care ◽  
Health Care Costs ◽  
Asylum Seekers ◽  
Health Care Services ◽  
Claims Data ◽  
Care Utilization ◽  
Care Services ◽  
Outpatient Sector ◽  
Analysis Of Claims Data ◽  
Care Costs

Abstract Background Asylum seekers are a vulnerable group with special needs in health care due to their migration history and pre-, peri- and postmigratory social determinants of health. However, in Germany access to health care is restricted for asylum seekers by law and administrative regulations. Methods Using claims data generated in the billing process of health care services provided to asylum seekers, we explore their utilization of health care services in the outpatient sector. We describe the utilization of outpatient specialties, prevalences of diagnoses, prescribed drugs and other health care services, as well as total costs of health care provision. Results The estimated prevalence for visiting an ambulatory physician at least once per year was 67.5% [95%-Confidence-Interval (CI): 65.1–69.9%], with a notably higher prevalence for women than men. The diagnoses with the highest one-year prevalence were “Acute upper respiratory infections” (16.1% [14.5–18.0%]), “Abdominal and pelvic pain” (15.6% [13.9–17.4%]) and “Dorsalgia” (13.8% [12.2–15.5%]). A total of 21% of all prescriptions were for common pain killers. Women received more diagnoses across most diagnosis groups and prescribed drugs from all types than men. Less than half (45.3%) of all health care costs were generated in the outpatient sector. Conclusion The analysis of claims data held in a municipal social services office is a novel approach to gain better insight into asylum seekers’ utilization of health services on an individual level. Compared to regularly insured patients, four characteristics in health care utilization by asylum seekers were identified: low utilization of ambulatory physicians; a gender gap in almost all services, with higher utilization by women; frequent prescription of pain killers; and a low proportion of overall health care costs generated in the outpatient sector. Further research is needed to describe structural and individual factors producing these anomalies.

Retrospective claims analysis of palliative care costs and survival in a U.S. metastatic renal cell (mRCC) population.

2012 ◽  
Vol 30 (5_suppl) ◽  
pp. 433-433
Author(s):  
Henry J. Henk ◽  
Connie Chen ◽  
Agnes Benedict ◽  
Jane Sullivan ◽  
April Teitelbaum
Keyword(s):  
Health Care ◽  
Health Care Costs ◽  
Health Plan ◽  
Index Date ◽  
Claims Data ◽  
Cohort Analysis ◽  
Hospital Costs ◽  
Best Supportive Care ◽  
Study Cohort ◽  
Care Costs

433 Background: Survival and costs outcomes for patients with mRCC receiving palliative or best supportive care (BSC) after stopping active therapy have been poorly characterized. This information is important to understand how resources are utilized at the end of life and to put current treatment costs into perspective. The objective of this retrospective database analysis was to examine survival and costs associated with BSC after receiving 1 or 2 lines of mRCC treatment. Methods: A retrospective cohort analysis using claims data from commercially insured or Medicare Advantage (MCR) enrollees of a large US health plan, with medical and pharmacy benefits. The study cohort consisted of patients with an index diagnosis for RCC [ICD-9-CM 189.0] from 1/1/07 to 6/30/10 initiating any of the following treatments from 30 days prior to index date through disenrollment: sunitinib, temsirolimus, sorafenib, bevacizumab, everolimus, pazopanib, cytokines. Patients were required to have a 6 mos. continuous enrollment ± index date (patients disenrolling due to death within the 6 mos. were retained). Lines of therapy (LOT) were identified based on prescription fill and administration dates, began following the last LOT and continued until disenrollment. Health care costs reported represent the health plan + patient paid amount. Results: The overall study cohort (n=274) was 73% male; mean (±SD) age 63.3 ± 11.1 yr. with the majority of patients commercially insured (80% vs 20% MCR). The majority started BSC following 1st LOT (68% vs 32%). Median survival from start of BSC was similar following 1st and 2nd LOT (126 and 118 days). The mean (median) duration of BSC after 1 LOT was 223 (114) days and 176 (109) days for 2 LOT. Total health care costs incurred during BSC averaged $50,187 ± 96,984 and $37,294 ± 51,101 and monthly costs were similar ($10,284 ± 17979) after 1 and 2 LOT, respectively. In both cases, inpatient hospital costs represented the largest proportion of these costs (47%) while outpatient costs represented 36%. Conclusions: Our study estimating BSC survival and costs in patients with mRCC based on US claims data found monthly cost of $10, 284. These estimates suggest that BSC costs are not insignificant.

scholarly journals Traversing the bridge from health care management practice to research

2006 ◽  
Vol 30 (4) ◽  
pp. 424
Author(s):  
Judith Dwyer
Keyword(s):  
Health Care ◽  
Care Management ◽  
Management Practice ◽  
Health Care Management ◽  
Care Practice ◽  
Services Research ◽  
Health Care Practice ◽  
Intractable Problems ◽  
Micro Level ◽  
Care Costs

IF THERE IS A BRIDGE from research to practice, I?ve been crossing against the traffic. In 2000, I moved from the increasingly tough world of health care management practice (thinking I?d done my share and it was someone else?s turn) and took up teaching and research (hoping I?d have time to reflect on and learn more about the intractable problems I?d been battling). Unfortunately I failed to consider, even though I ?knew?, that universities are also operating in an increasingly tough world, and academic work has also been intensified. But my crossing did coincide with an emerging focus on health services research, which ?examines how a variety of factors ? from financing systems to medical technologies to personal behaviors ? affect health care costs, quality, and access?.1 It is a broad field, spanning research on the macro policy settings (how to fund health care, who gets access) through to the micro level of health care practice (for example, how clinicians might work with patients who have chronic conditions as partners in the management of their care).

scholarly journals Health care management resources: Web sites for the national debate

2009 ◽  
Vol 70 (8) ◽  
pp. 460-464
Author(s):  
Shikha Sharma
Keyword(s):  
Health Care ◽  
Web Sites ◽  
Care Management ◽  
Health Spending ◽  
Universal Coverage ◽  
The United States ◽  
Health Care Spending ◽  
Price Controls ◽  
National Debate ◽  
Care Costs

According to the Centers for Medicare and Medicaid Services (CMS), the United States is projected to spend more than $2.5 trillion on health care in 2009, or $8,160 per U.S. resident. Health spending in 2009 is projected to account for 17.6 percent of gross domestic product.1 Despite high spending, nearly 46 million Americans are still uninsured. While policy and law makers agree that health care reform is needed, they disagree on how to contain the escalating health care costs and offer universal coverage. Some have suggested imposing price controls and strict budgets on health care spending, and others support free . . .

Socioeconomic Costs and Health Inequalities from Psoriasis: A Cohort Study

Dermatology ◽  
2019 ◽  
Vol 235 (5) ◽  
pp. 372-379 ◽  
Author(s):  
Simon Francis Thomsen ◽  
Lone Skov ◽  
Rikke Dodge ◽  
Morten Storling Hedegaard ◽  
Jakob Kjellberg
Keyword(s):  
Health Care ◽  
Health Care Costs ◽  
Odds Ratio ◽  
Care Management ◽  
Health Care Management ◽  
Indirect Costs ◽  
National Patient ◽  
Matched Study ◽  
The Impact ◽  
Care Costs

Background: To date, there are no nationwide studies of the social and economic burden of psoriasis to patients in Denmark. Incentives for health care management based on patient-related outcomes and value (IMPROVE) in psoriasis and psoriatic arthritis is a project aimed at assisting movement from activity-based to outcome-based health care management. One of the key objectives in IMPROVE is to describe the disease-associated socioeconomic burden of psoriasis. Methods: A case-matched study of the impact of psoriasis on patients’ income, employment and health care costs in Denmark was performed. The IMPROVE study was a retrospective analysis of patients with a hospital diagnosis of psoriasis identified from the Danish National Patient Registry (NPR). In total, 13,025 psoriasis patients and 25,629 matched controls were identified from the NPR. Data from psoriasis patients and matched controls were compared for social and economic factors including income, employment, health care costs and risk of comorbidities. Results: Psoriasis was associated with increased health care costs (mean annual costs +116% compared to control, p < 0.001), peaking in the year of referral to hospital for psoriasis and sustained thereafter. Both direct and indirect costs were significantly higher for patients with psoriasis than controls (p < 0.001). In the years before and immediately following hospital diagnosis, the rates of employment were lower in psoriasis patients than controls. Comorbidities, including cardiovascular (odds ratio 1.93 [95% CI 1.77–2.09]) and psychiatric conditions (odds ratio 2.61 [95% CI 2.30–2.97]), were more prevalent in patients with psoriasis than controls. Conclusion: In Denmark, psoriasis has a significant impact on health care costs, income and employment, and is associated with a range of comorbidities.

scholarly journals The importance of health insurance claims data in creating learning health systems: evaluating care for high-need high-cost patients using the National Patient-Centered Clinical Research Network (PCORNet)

2019 ◽  
Vol 26 (11) ◽  
pp. 1305-1313 ◽  
Author(s):  
Maureen A Smith ◽  
Mary S Vaughan-Sarrazin ◽  
Menggang Yu ◽  
Xinyi Wang ◽  
Peter A Nordby ◽  
...  
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Case Management ◽  
Health Care Utilization ◽  
Health Systems ◽  
Claims Data ◽  
Care Utilization ◽  
Insurance Claims Data ◽  
Health Insurance Claims Data ◽  
Health Insurance Claims

Abstract Objective Case management programs for high-need high-cost patients are spreading rapidly among health systems. PCORNet has substantial potential to support learning health systems in rapidly evaluating these programs, but access to complete patient data on health care utilization is limited as PCORNet is based on electronic health records not health insurance claims data. Because matching cases to comparison patients on baseline utilization is often a critical component of high-quality observational comparative effectiveness research for high-need high-cost patients, limited access to claims may negatively affect the quality of the matching process. We sought to determine whether the evaluation of programs for high-need high-cost patients required claims data to match cases to comparison patients. Materials and Methods A retrospective cohort study design with multiple measures of before-and-after health care utilization for 1935 case management patients and 3833 matched comparison patients aged 18 years and older from 2011 to 2015. EHR and claims data were extracted from 3 health systems participating in PCORNet. Results Without matching on claims-based health care utilization, the case management programs at 2 of 3 health systems were associated with fewer hospital admissions and emergency visits over the subsequent 12 months. With matching on claims-based health care utilization, case management was no longer associated with admissions and emergency visits at those 2 programs. Discussion The results of a PCORNet-facilitated evaluation of 3 programs for high-need high-cost patients differed substantially depending on whether claims data were available for matching cases to comparison patients. Conclusions Partnering with learning health systems to rapidly evaluate programs for high-need high-cost patients will require that PCORNet facilitates comprehensive and timely access to both electronic health records and health insurance claims data.

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