 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
From the * University of Texas Southwestern Medical Center at
Dallas, Department of Pediatrics, Dallas, Texas; and the University
of Texas Health Science Center at Houston, School of Public Health,
Houston, Texas.
ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ACKNOWLEDGMENT
ABBREVIATIONS
REFERENCES
ABSTRACT 
Objective. Despite uncertain validity as a measure of cost, Medicaid reimbursements may be used to compare the costs of different pediatric interventions. We explored the credibility of Medicaid reimbursements as a measure of the costs of inpatient care associated with two different approaches to follow-up care for high-risk indigent infants.
Design. Analysis of Medicaid reimbursements within a randomized trial of primary follow-up care.
Patients. Infants 
1500 g at birth in a large county
hospital (Parkland Memorial Hospital).
Intervention. Conventional care after nursery discharge (with well-baby care and care for chronic illnesses provided in our follow-up clinic) or primary care (with care for acute illnesses also provided in the follow-up clinic). Measures to prevent a lapse in Medicaid coverage were included in all clinic visits.
Outcome Measures. The completeness, comparability, and plausibility of Medicaid reimbursements for inpatient care of the two groups between nursery discharge and 1 year adjusted age.
Results. A high percentage (90% to 91%) of both groups were enrolled in Medicaid. However, with fewer clinic visits in the conventional care group, Medicaid coverage often lapsed in this group, particularly among the highest risk infants. As a result, the proportion of hospital days reimbursed by Medicaid was substantially lower for conventional care than primary care infants (53% [92/174] vs 96% [298/310]). An even larger disparity was observed for pediatric intensive care days (10% [6/61] vs 100% [33/33]). Implausible Medicaid reimbursements included a lower reimbursement rate per day in the pediatric intensive care unit than on the pediatric floor (1 infant), a lower reimbursement rate per day for hospital care than home care (1 infant), and a mean reimbursement rate per day for our private pediatric teaching hospital ($1244/day) that did not exceed that for the private nonteaching pediatric hospital ($1268/day). The reimbursement rate for our public teaching hospital was particularly low ($507/day) despite a high acuity of illness (21% of hospital days in the pediatric intensive care unit).
Conclusions. Without proper validation, reimbursements from Medicaid (or any program that replaces it) should not be assumed to provide an unbiased or acceptably accurate measure of the relative or absolute cost of pediatric health care interventions. primary care, follow-up care, cost, Medicaid, economic analysis, health care delivery.
INTRODUCTION
Informed decisions in allocating limited resources for health care require an understanding of not only the health effects but also the resource costs of different health care interventions.1 Unfortunately, the assessment of these costs has proved to be a very difficult problem.1
Resource costs can be accurately evaluated by an intensive direct assessment.2 However, such an assessment is a very demanding and expensive process that has rarely been used.3 Hospital charges have often been used as a proxy for costs.4 However, traditional hospital accounting systems were not designed to reflect resource costs but to assure collection of revenues.1 The charge for a specific service has no necessary or predictable relationship to the actual cost to provide the service1,9 (see "Discussion"). For this reason, the use of charge data may lead to erroneous conclusions about the cost-effectiveness of different health care interventions.10
An alternative approach is to use Medicaid or Medicare reimbursements11 under the assumption that the approved reimbursements for different interventions are a reasonably accurate indicator of their absolute and relative resource costs. Medicare reimbursements have often been used although they "require much evaluation and `massaging'" before they can be properly used.12 Medicaid data are more limited than Medicare data in terms of completeness, continuity, and uniformity. Yet, data for Medicaid (or any similar program that replaces Medicaid) may be the only financial data available for large numbers of pediatric patients in the United States.
In this article we present a pilot study performed to assess the credibility of Medicaid reimbursements as a measure of the hospital costs associated with two different approaches to the care of indigent high-risk infants. This pilot study was performed within an ongoing randomized trial of conventional and primary follow-up care for inner-city survivors of newborn intensive care.
METHODS
Purpose of Clinical Trial
The trial is being conducted to test the hypothesis that primary follow-up care reduces life-threatening illnesses
defined as illnesses
resulting in death or admission to a pediatric intensive care unit
(PICU)in a high-risk population. To prevent mild or moderate
illnesses from progressing to life-threatening illnesses, primary care
is expected to increase costs for clinic visits and perhaps hospital
days on the pediatric floor. However, these increases may be totally or
largely offset by a reduced cost for hospital days in the PICU.
Population
Infants born at Parkland Memorial Hospital, the county hospital for Dallas, Texas, and the primary teaching hospital in our medical center, are eligible for the trial if their birth weight (BW) is less than 1000 g or if their BW is 1001 to 1500 g and they require mechanical ventilation during the first 2 days after birth. We have previously shown that such infants have high mortality, morbidity, and care needs throughout infancy.13 Ninety-eight percent of the infants have been eligible for Medicaid coverage.Patient Care
Infants randomized to the conventional care group receive care for chronic illnesses in addition to well-baby care, anticipatory guidance, and developmental testing in our follow-up clinic at Children's Medical Center, a private pediatric teaching hospital adjacent to Parkland. This care is provided two mornings per week by a multidisciplinary team. Care for acute illnesses is provided in clinics in the community or in other clinics or the emergency room in our center.Enrollment in Medicaid
If such coverage was not arranged in the prenatal clinics, an application is initiated before the mother's discharge from the hospital. At each clinic visit or hospitalization of the infant, a financial counselor assists in securing Medicaid coverage that has lapsed or was not obtained.Identification of Medical Services and Medicaid Reimbursements
An evaluator blinded to the group assignment reviews all clinic and hospital charts at Parkland and Children's Medical Center. Our infants routinely receive care only in these hospitals. However, we used maternal reports and Texas Medicaid data to identify all hospitalizations. All records for services billed to Medicaid between nursery discharge and 12 months adjusted age for infants in this analysis were provided by National Heritage Insurance Company, the private corporation responsible for processing Texas Medicaid claims. The interval between the last day of the hospitalization and the tabulation of Medicaid payments allowed no less than 9 months to process all Medicaid claims for all infants in both groups. The same procedure to identify reimbursements was used for both groups, and the personnel at the National Heritage Insurance Company were not aware of treatment group.Criteria for Assessing Medicaid Reimbursements
We assessed reimbursements for inpatient care because the costs for such care are likely to be the predominant medical cost for both groups. Comparability and Completeness of Medicaid Coverage for the Two Groups Under Texas law, periodic recertification is required for continued Medicaid coverage. Because of differences in clinic attendance, coverage would be expected to lapse less often among primary care infants than conventional care infants, particularly among the highest risk infants. We assessed the study groups with respect to the percent of infants covered at any time during the first year, percent of infant-months covered, percent of hospital days covered, and percent of PICU days covered. For each of these variables, we considered a Medicaid coverage rate of less than 90% to be inadequate to assess hospital costs. Comparability and Completeness of Medicaid Reimbursements for the Two Groups Reimbursements may not be provided for infants with Medicaid coverage, largely because the claim is not submitted (or appealed) by the hospital within the allowable time. Delayed submission is most likely when recertification is required. For reasons noted above, primary care infants may be less likely than conventional care infants to need recertification. We compared the two groups with respect to the percent of hospital days and PICU days for which any Medicaid reimbursements were received. We considered Medicaid reimbursement to be an inadequate measure of cost if reimbursement were received for fewer than 90% of hospital days. We made no attempt to assess whether all appropriate reimbursements were provided. Thus, our analysis provides a liberal assessment of the completeness of Medicaid reimbursements in each group. Plausibility of Medicaid Reimbursement Data as a Measure of Cost Implausible findings include a) an equal or lower reimbursement rate per day for intensive care than for a lower level of care in the same hospital or at home, and b) an equal or lower reimbursement rate per day for teaching hospitals than for nonteaching hospitals. With the costs involved in training physicians, higher mean costs are expected in teaching hospitals,14 particularly if, as in our region, the teaching hospitals are responsible for providing pediatric intensive care to indigent patients. The mean Medicaid reimbursement per day for a specific hospitalization was computed by dividing the total reimbursement by the total hospital stay. The overall mean was calculated as the average of the means for all hospitalizations for which Medicaid reimbursements were provided. The charges submitted to Medicaid as well as the reimbursements were assessed in a similar fashion. Hospitalizations outside of Texas were not considered in comparing charges or reimbursements for Parkland and Children's with those for private nonteaching hospitals. Statistical Analysis Two-tailed Fisher's exact tests were used to assess differences between groups in proportions (of infants, infant-months, hospital days, or PICU days with Medicaid coverage or reimbursement). Statistical analyses were considered inappropriate or unnecessary in identifying findings that are implausible if Medicaid reimbursements indicate true resource costs (eg, a lower reimbursement rate for PICU care than for home care of the same infant; the absence of a higher mean reimbursement rate for a private teaching hospital than a private nonteaching hospital). All statistical tests were performed using Stata software, Release 3.1 (Stata Corporation, College Station, TX). P values less than .05 were considered statistically significant.RESULTS
Completeness and Comparability of Medicaid Coverage
Given the effort to enroll infants in Medicaid before nursery discharge, 91% (39/43) of the primary care group and 90% (36/40) of the conventional care group were enrolled during infancy. However, with the recertification requirements, Medicaid coverage lapsed less in the primary care than in the conventional care group (3/39 vs 10/36; P = .03). Coverage was particularly likely to lapse among the highest risk infants in the conventional care group. As a result, Medicaid coverage in the conventional care group was less than 90% and lower than the primary care group when expressed as the percent of infant-months covered, the percent of hospital days covered, and especially the percent of PICU days covered (P < .05 for all comparisons) (Fig 1).
Completeness and Comparability of Medicaid Reimbursements
Reimbursements (of any amount) were provided for considerably fewer than 90% of hospital days and PICU days for the conventional care group. Such reimbursements were provided for only 53% of hospital days and 10% of PICU days among the conventional care group, compared with 96% and 100%, respectively, for the primary care group (P < .01) (Fig 2).
Implausible Medicaid Reimbursement Data
For one primary care patient, the Medicaid reimbursement rate per day was higher on the general pediatric floor than in the PICU in the same hospital ($1039/day vs $661/day). For another primary care patient, the daily Medicaid reimbursement per day was higher for home health care than for the PICU ($1465/day vs $1206/day).
DISCUSSION 
Fig. 3.
Mean Medicaid charges and reimbursements within Texas by hospital type
for infants with Medicaid coverage. Data represents 16 admissions for
151 days in the public teaching hospital, 23 admissions for 188 days in
the private pediatric teaching hospital, and two admissions for 101 days in the private nonteaching hospital. (Standard deviations for
hospital charges were 654, 953, and 1538; standard deviations for
hospital reimbursement were 290, 458, and 351, respectively).
[View Larger Version of this Image (22K GIF file)]
FOOTNOTES
Received for publication Nov 2, 1995; accepted Jun 6, 1996.
Reprint requests to (R.S.B.) University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, 5323 Harry Hines Boulevard, Dallas, TX 75235-9063.
ACKNOWLEDGMENT
Supported by grant RO1 HSO6837 from the Agency for Health Care Policy and Research.
ABBREVIATIONS
PICU, pediatric intensive care unit. BW, birth weight.
REFERENCES
are continued efforts in the emergency department
justified?
N Engl J Med.
1991;
325:1393-1398 [Medline][Abstract]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
||
|
||
Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 1997 American Academy of Pediatrics. All rights reserved. |
||
|
||
