Chapter 6: Competition Law: Insurers

resource utilization

For example, drug prices for large institutional purchasers may be 10%-20% lower than average wholesale prices, and expected future costs of generic alternatives may be lower still. More generally, the results of such comparisons are sensi­tive to the methodologies used and to the types of people included in the analysis. To examine that sensitivity, CBO conducted its own analysis of MEPS data to track changes in insurance coverage from year to year. Grouping people on the basis of their coverage in the first year was designed to limit the extent to which people gaining or losing cover­age in the second year differed with respect to their atti­tudes toward health insurance and medical care.

  • Health plans use a variety of other practices to contain health care costs.
  • Panelists noted that there is no absolute market share threshold above which a firm may be able to employ an MFN anticompetitively.157 Indeed, the relevant source of market power depends on whether the theory of harm focuses on seller-side or buyer-side imposition of the MFN.
  • A 1-year study interval from April 1, 2011 through March 31, 2012 was used in the analysis.
  • Association of Income Disparities with patient-reported healthcare experience.
  • For purposes of calculating the direct component of the rate, the department shall utilize the allowable direct costs reported by all facilities with the exception of specialty facilities as defined in subdivision of this section.

The prices private health plans pay for prescription drugs are based on formularies. The 21st Century Cures Act, passed in 2016 to promote the use of EHRs overall, requires that all health care providers make electronic copies of patient records available to patients, at their request, in machine-readable form. Outpatient specialists are free to choose which form of insurance they will accept.

Availability of data and materials

The cumulative and average costs for the entire decade of follow-up were determined based on the entire cohort. We compared the average per capita cumulative cost of care for type 1 and type 2 diabetes after adjusting for age, sex, and comorbidities using ANCOVA models. Health care services (i.e., prescriptions, physician visits, hospitalizations, day surgeries, and dialysis) in each calendar year were identified from services recorded in the databases.

medical services

This review followed the five core stages of scoping reviews outlined in the methodological framework by Arksey and O’Malley . System, hospital, provider, and community characteristics influence low value care provision. To improve health care value, strategies aiming to reduce utilization of low value services and promote high value care across various levels will be essential. For purposes of inclusion in facility rates for 1991, the annual incremental per diem add-on shall be effective for the nine month period beginning April 1, 1991 and further adjusted so that the nine months of incremental cost are reflected in a per diem adjustment for July 1, 1991 through December 31, 1991 rates. Based on the most current 1986 PRI’s filed with the Department, the number of eligible dementia patient days for Medicaid patients admitted prior to December 31, 1987, is estimated to be 1,750,000. Aggregate changes in such number in excess of 5% shall be deemed to be attributable to factors other than changes in patient condition and shall result in the recalculation and proportionate, prospective reduction of the per diem amount referred to in paragraph of this subdivision.

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We were unable to capture resource use and costs for diabetes educators, dietitians, and podiatrists, as well as the auxiliary costs of transplants and laboratory services after 1993, because these are managed under regional health budgets. Before 1993, funding of laboratory services was reflected in fee-for-service physician billings, but these were no longer included after this year. We were also unable to capture other expenditures such as emergency department services or directly capture dialysis costs, although we are confident that the prospective costing data we used to estimate the latter is both valid and accurate . It should also be noted that day surgery and hospital costs were not obtained directly from Saskatchewan Health records but were estimated by applying costs from external sources to records obtained directly from Saskatchewan Health. Furthermore, the same estimation approach was used for all subjects, so there was no bias in the comparison between type 1 and type 2 diabetic patients.

By 2001, however, the per capita dialysis Identifying Incremental Cost In Hmo for type 1 diabetes had reached $1,098, which was almost five times the per capita cost for type 2 diabetes ($227) in the same year . After 1996, dialysis costs in the type 1 diabetes cohort by far exceeded those of the type 2 diabetes cohort. Overall, ∼31.5% of dialysis costs were for peritoneal dialysis and 68.5% were for hemodialysis.

Quality appraisal

An ideal economic evaluation of these technologies would explicitly measure all direct healthcare costs and direct non-healthcare costs as well as indirect costs that could be affected by an intervention. Additionally, the full enumeration of the total costs needs to be synthesized with the consequences of the intervention. Willingness to implement proven depression treatment programs will depend on the balance of additional benefits and additional costs. Cost-effectiveness analyses of 2 of the interventions described earlier in the introduction show modest increases in outpatient treatment costs.15,16 Neither of these studies examined the effect of improved depression treatment on overall health services utilization.

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