Johns Hopkins Carey Business School, 100 International Drive, Baltimore, MD, 21202, USA.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
BMC Health Serv Res. 2022 Feb 14;22(1):201. doi: 10.1186/s12913-022-07523-3.
Many payers and health care providers are either currently using or considering use of prior authorization schemes to redirect patient care away from hospital outpatient departments toward free-standing ambulatory surgical centers owing to the payment differential between these facilities. In this work we work with a medium size payer to develop and lay out a process for analysis of claims data that allows payers to conservatively estimate potential savings from such policies based on their specific case mix and provider network.
We analyzed payment information for a medium-sized managed care organization to identify movable cases that can reduce costs, estimate potential savings, and recommend implementation policy alternatives.
We analyze payment data, including all professional and institutional fees over a 15-month period. A rules-based algorithm was developed to identify episodes of care with at least one alternate site for each episode, and potential savings from a site-of-service policy.
Data on 64,884 episodes of care were identified as possible instances that could be subject to the policy. Of those, 7,679 were found to be attractive candidates for movement. Total projected savings was approximately $8.2 million, or over $1,000 per case.
Instituting a site-of-service policy can produce meaningful savings for small and medium payers. Tailoring the policy to the specific patient and provider population can increase the efficacy of such policies in comparison to policies previously established by other payers.
由于医疗机构之间的支付差额，许多付款人和医疗保健提供者目前正在使用或考虑使用预先授权计划，将患者护理从医院门诊部门转移到独立的门诊手术中心。在这项工作中，我们与一家中等规模的付款人合作，开发并制定了一种分析索赔数据的流程，使付款人能够根据其特定的病例组合和提供商网络，保守估计此类政策的潜在节省。
我们分析了一家中等规模管理式医疗组织的支付信息，以确定可以降低成本的可移动病例，估算潜在的节省，并为实施政策替代方案提供建议。
我们分析了支付数据，包括 15 个月期间的所有专业和机构费用。开发了一个基于规则的算法，以识别每个病例至少有一个替代地点的护理病例，并从服务地点政策中节省潜在的费用。
确定了 64884 次护理病例的数据，这些数据可能是该政策的适用对象。其中，有 7679 例被认为是可转移的有吸引力的候选病例。总预计节省约为 820 万美元，即每个病例超过 1000 美元。
对于小型和中型付款人来说，实施服务地点政策可以产生有意义的节省。根据特定的患者和提供者人群定制政策，可以提高这些政策相对于其他付款人先前制定的政策的效果。
