I get paid fast; what about you?

The process of billing an insurance company for health care services has changed radically. In the past few years, the emphasis has been on automation. The change is fueled by the opinion of cost containment experts who claim that automation will help reduce costs in the U.S. health care delivery system. Key to success for the provider in adapting to this change will be understanding the coding used in the billing process and following standards of accuracy and fairness. This article is not intended to represent the adjudication rules of any particular insurance company. It is the result of experience as a practicing surgeon and as a consultant in the health care field.     

Cost shifting: the final straw in federalization of health care

While cost controls applied by Medicare and indemnity insurance programs initially helped curtail abusive medical billing practices, creative billing techniques have since resulted in runaway medical costs and rising insurance premiums. Employers have been forced to increase employee's contributions to health care by increasing deductibles, copayments, and coinsurance or by simply dropping health care benefits. If National Health Insurance comes to pass, and that is a cry now coming from major employers, it will be followed in time by federalization of all health care delivery systems, including Workers' Compensation. It is the providers who shift their fees into Workers' Compensation, which pays from the first dollar, who will cause the business community to petition Washington for relief. It will claim the need for cost controls in Workers' Compensation to keep American business competitive in world markets.     

Effectiveness, accountability, and efficiency

Management of health care is compromised by its singular reliance on billing information--i.e., a claims trail tells little of what providers think. It relates to neither prevention of disease nor reduction of unnecessary health care costs. Billing information is not the substrate to be used in the pursuit of appropriateness, effectiveness, and value. To improve medical management of health care, a protected, but accessible clinical database is needed.     

Health care costs tied to many issues

Although, in 1990, the United States spent about $750 billion (12.2 percent of the Gross National Product) on health care, 31-37 million people in this country are uninsured. Another 4 million people are thought to be underinsured. We have one of the highest infant mortality rates among developed industrialized nations and rank 19th in health care and well-being among those nations. Our life expectancy is lower than those of some third-world countries. The United States and South Africa are the only two industrialized nations without a national health care policy. In spite of these statistics, U.S. health care costs continue to rise and, by the year 2000, are expected to reach $1.5 trillion (15 to 17.5 percent of the GNP. Per capita spending on health care will reach $5,515 by the year 2000, compared with $2,425 in 1990 and $1,016 in 1980.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.     

Would Allowing Privately Funded Health Care Reduce Public Waiting Time? Theory and Empirical Evidence from Canadian Joint Replacement Surgery Data

This study develops a theoretical model and then, using Canadian joint replacement surgery data, empirically tests the relationship between government policies that promote privately funded health care and patients’ waiting time in the public health care system. Two policies are tested: one policy allows opt‐out physicians to extra‐bill private patients, and the other provides public subsidies to private patients. We find that both policies are associated with shorter public waiting time, and that the subsidy policy appears to be more effective in waiting time reduction than the extra‐billing policy. Our findings are consistent with a dominant demand‐side effect in that these policies would provide patients an option, and some incentive, to opt out of the public health system, shifting the demand from the public health system to the private care market.     

The looming millennium bug

Evaluating and fixing date sensitive systems by the year 2000 is a significant challenge for the health care industry. Health care executives will be engrossed in this important management activity over the next several months. By now all critical business functions should have been identified and remediated. Contingency planning to ensure the continuity of high quality systems is an essential next step. Physician executives need to have a contingency plan in case Y2K-related failures occur. Most health care facilities have a disaster plan that has been tested in clinical scenarios. These plans should be reviewed to ensure they include procedures for handling problems with office operations, power outages, equipment failure, supply or pharmaceutical shortages, and patient evacuation. Financial systems are at risk at multiple points, including determining eligibility, claims submission, billing, and payments.     

Meet the mandate to measure clinical quality

The mandate for health care organizations to be accountable for quality, as well as price, is now unavoidable. The Joint Commission's ORYX project is requiring every hospital to measure clinical outcomes of a majority of its patients within the next three years. This mandate can be met best with systems of clinical outcomes measurement that provide valid, reliable risk adjustment; yield meaningful information about many different diseases and procedures; and measure more than mortality or cost--all using primarily billing data. New outcomes measurement tools with all of these capabilities are available and have already enabled quality improvement in dozens of hospitals across the U.S.     

基于变量选择和遗传网络规划的期货高频交易策略研究

高频交易在当前国际金融市场上炙手可热,股指期货的推出、融资融券和转融通业务的开通,使得我国高频交易市场初现端倪。本文立足于我国金融衍生品市场的现状提出了基于LASSO变量选择方法和遗传网络规划的期货高频交易策略。该策略首先使用LASSO从众多技术指标中,选出极少数最有效的指标作为判断函数,然后通过一种进化算法遗传网络规划来搜索合适的买点和买点,从而构建交易策略,并以黄金、铝和橡胶期货的5分钟高频交易数据为例进行回测检验。结果显示:第一,与最优子集法相比,LASSO方法在不降低预测精度的情况下,选出的指标数量最少,且均集中在趋势指标和震荡指标中。第二,通过结合遗传网络规划模型与Q强化学习法,搜索效率得到了显著提高,构建出适合于衍生品市场的简洁有效的交易策略,且在不同品种的期货交易中均超越了"买入并持有"策略,并获取超额收益,在量化投资领域充分体现了实践价值。     

One-stop health care shopping in America--made in India

A multispecialty group practice in southern Maryland offers patients a multitude of services, while all billing and record keeping is completed overnight in India.     

The paradoxes of national health reform during the Wilson era

The current debate over health care reform may represent yet another opportunity to establish a national health policy. A similar level of activity occurred during the presidency of Woodrow Wilson. In many ways, the failure to enact national health reform (NHR) in the early 20th Century represents a paradigm for subsequent failed attempts to enact NHR.     

The Economic Impact of Health Policy Interventions

The rapid aging of the U.S. population, increases in the absolute prevalence of chronic diseases, and the associated rise in the proportion of the GNP expended on medical care all indicate the need for methods to accurately forecast future health care expenditures for specific chronic diseases. Additionally, if these methods are biomedically realistic, they can be used to evaluate the economic implications of specific prevention strategies designed to reduce chronic disease incidence, prevalence, and mortality. Projection strategies that are not biomedically realistic, such as models that assume that risks for demographic subgroups do not change over time (e.g., "static component" models), though possibly accurate over the short run, are not suitable for assessing the long term effects of specific proposed health policy interventions which are designed to alter risks.
In this paper we present a strategy for forecasting health care costs which is based on a model that represents the natural history of a chronic disease in terms of a preclinical state, a clinical state, case fatality rates, cures, and the implications of exogenous medical factors. Using this model we project that the treatment costs associated with respiratory cancer in the white male population of the U.S. may undergo a two-thirds increase in real dollars over the period 1977 to 2000. About one-half of this increase is due to a demographic shift to an older population structure, with the remainder due to higher respiratory cancer incidence rates in younger cohorts. Alteration of certain parameters of the model to simulate various interventions suggests that about three-quarters of the cost of this disease could be eliminated, though realization of any significant part of this savings would require a lengthy phase-in period.     

Why Rates of Growth of Employment Differ: A Quantitative Approach to an International Comparison

ABSTRACT: This essay aims at presenting a quantitative assessment of the incidence of structural differences in output and employment composition, and of differential dynamics of the sectoral production and productivity, in order to explain the divergences in net employment growth in advanced market economies. The point of reference is the extremely divergent record, in terms of employment creation, of the United States on one hand, and Western European countries on the other. In the period 1973-80, for example, although the average growth rates of GNP were, on a cyclical average, similar in the U. S. A. and the EEC areas as a whole, additional job openings were about 14 million in the USA against less than half a million in the EEC. A structural, medium-run differential in the aggregate Employment/GNP elasticity appears to have characterized the performances of these economic systems. The 'source’of this differential are analyzed, utilizing a model of sectoral decomposition of employment and output trends. Simulation exercises are carried out, in order to assess the specific role of productivity, sectoral demand composition and sectoral employment composition, in determining the overall elasticity result. The comparative analysis takes into consideration the differential factors for the USA and Japan, together with the four major Western European countries (German Fed. Rep., France, Italy, and the United Kingdom).     

Improving human resources for health planning in developing economies

There is a universal consensus that human resources represent the heart and soul of effective health systems everywhere. However, despite this consensus, human resource planning in low income countries remains a neglected, often poorly implemented and ineffective component of health-system development. The planning exercises that do take place are often inefficient, use inappropriate planning models or fail to adequately prioritize human resource investment decisions. This article briefly discusses possible reasons why this failure occurs and describes four key steps that can help health system planners more effectively prioritize and link human resource for health investment decisions to health system strategy and programmatic initiatives. Implications for human resource development practice and national human resource development are discussed.     

Self-directed health plans: alternatives to managed care enabled by new technologies

Few people believed the Internet would have much impact on the delivery of health care services. However, combined with technological advances in how computer systems are structured and implemented and knowing what doesn't work in managed care from bitter experience, the Internet is being used to create a new paradigm of alternative health insurance products. These products hold the potential to change for the better the face of health care as we know it. Self-directed health plans will be less expensive than managed care programs and offer greater predictability in health care spending. For health care providers, SDHPs' reliance upon episode allowances will create a new market for packaged or bundled services. Providers will be paid to provide solutions, not just treatment. This could represent a new model in which physicians accept a risk-adjusted payment and provide a warranty that they will do whatever necessary until the patient has reached the reasonably expected health status. This is a radical departure from the fee-for-service or capitation system.     

Do these guys know why they're applauding?

Contained in Title IV, Section 6102, of the Omnibus Budget Reconciliation Act of 1989 are more than 21 pages of legislative language designed to require the Health Care Financing Administration (HCFA) to set all physicians' fees for services delivered under Part B of Medicare commencing January 1, 1992, and phased in over the following four years. In addition, balance billing dollar limits keyed to the regulated rates are set forth, as are "Volume Performance Rates of Increase," a reincarnation of a vehicle previously known as "Expenditure Targets."     

Why textile and clothing industries are shifting to the third world

The 1970s witnessed important changes in the international division of industrial labour. Textiles and clothing were the major examples of industries where comparative advantage shifted in favour of developing countries. The present article discusses the reasons why textiles and clothing are important at the early stage of industrialization. It then examines the statistical relationship between the size of these industries and GNP per capita levels and finds this to be strongly negative. The article concludes that this points to the unrealistic nature of developed countries' attempts to maintain textile and clothing industries at their present size through protectionism, and that this will be an inadequate response to future changes in the international division of labour.     

Breaking away

While life as hospital employees was comfortable, the lure of independence won out for these two emergency department physicians. Breaking away to develop a new company was not easy, but it's paid off for the entrepreneurs of the Capital Region Emergency Medicine, P.C. Developing an emergency medicine business meant learning all aspects of business: billing services, evaluating legal services, raising capital, and becoming employers. The advantage has been an ability to use profits to improve the moral of staff, an increase in salary, and an overall sense of satisfaction.     

But 'twas a famous victory

The Omnibus Budget Reconciliation Act of 1989 sets forth the basic parameters for physician payment reform. The program requires the Health Care Financing Administration to (1) set (regulate) all physicians' fees for services delivered under Part B of Medicare commencing January 1, 1992, with a four-year phase-in period, (2) limit the dollar amounts of balance billing by tying those amounts to the regulated rates, and (3) establish "Volume Performance Standard Rates of Increase" (previously known as "Expenditure Targets") as a mechanism for attempting to regulate the quantities of services delivered.