Geographic Variation Within the Military Health System

Background: This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS). Methods: Data for fiscal years 2007 – 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF. Results: Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas. Conclusions: In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare

Oporezivanje digitalnih usluga u republici Hrvatskoj : završni rad

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A Systems Approach to Person-Centric Health Economics

The economics of health and the economics of health care are not the same, and in fact can be competitors for resources in some cases. Using a traditional supply/demand framework can clarify the forces at work in person-centric health economics. Use of cost-effectiveness analysis, employing a broader systems perspective that incorporates sectors other than health care, and nudging individuals to better health habits are three strategies that can help to drive a shift from health care to health

Geographic Variation within the Military Health System

Research Objective: This study sought to quantify variation in utilization of six surgical procedures and in per capita cost using system-defined geographic regions within the Military Health System (MHS). Study Design: A retrospective cohort approach was used to analyze rates of utilization (hip replacement, knee replacement, coronary artery bypass graft, prostatectomy, and C-section) and per capita cost using MHS-defined regions (catchment areas) of enrollee residence as the unit of analysis. Areas where fewer than five procedures were performed were excluded. Since age and gender have been found to account for very little of geographic variation, unadjusted utilization rates and per capita costs were used. Population Studied: This analysis studied 3.6M adult Tricare Prime Enrollees (including Active Duty service members, retirees, and their dependents) for the period for Fiscal Years 2007 and 2010 living in the United States. Tricare Prime is a HMO-like option for beneficiaries of the MHS. Prime enrollees are assigned a primary care manager who directs patient care, meaning a greater level of control should be in place for these enrollees. Principal Findings: Variation, as measured by the coefficient of variation (CoV), was generally high for both cost and utilization. Per capita cost CoV was .29 for 2010 and .28 for 2007. By comparison, the CoV for Medicare per capita cost for Health Referral Regions from the Dartmouth Atlas was 15% for 2010. Utilization CoVs for 2010 ranged from .26 for C-sections (as a percentage of live births) to .48 for prostatectomies, and utilization CoVs for 2007 ranged from .24 for C-sections to .54 for knee surgeries. Procedures with lower rates generally had greater variation. A low but inverse correlation (-0.28) was found between the aggregate amount of care received in military facilities (versus private sector care) and overall utilization for back surgeries for a given catchment area. Conclusions: Organized health systems such as the MHS might be expected to exhibit less variation than that documented for either Medicare or commercial insurance beneficiaries. These findings contradict this hypothesis, suggesting that other factors may be affecting to what extent variation occurs. Improved communication among military treatment facilities and a recently implemented ‘enhanced multi-service market’ strategy may help reduce variation. Moreover, design of managed care contracts for private sector care may offer a venue to discourage unwarranted care system-wide. Future analysis should confirm the role of age, gender, and race in this variation. Implications for Policy or Practice: The Military Health System appears to be subject to the same cost pressures as the greater U.S. health system. Quantifying variation is an essential first step in reducing unwarranted variation in the provision of health care. Understanding the underlying mechanisms contributing to the findings of this study would assist not only leaders of the MHS, but also policy-makers for the US health system to determine if and where unwarranted care is being provided within the system

Geographic variation within the military health system

Abstract Background This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS). Methods Data for fiscal years 2007 – 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF. Results Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas. Conclusions In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare

Trends in Diffusion of Surgical Innovation and Outcomes: A Comparative Analysis of Radical Prostatectomy in Military and Civilian Institutions

Introduction: Private civilian institutions exist in a financial environment that engenders competition for patients to increase profits, and, in theory, competition can promote clinical innovations. We sought to determine whether reimbursement structure altered the adoption of minimally invasive radical prostatectomy (RP), and if differential adoption was associated with a difference in clinical outcomes. Methods: A retrospective cohort review from the Tricare administrative data looked at men with prostate cancer (ICD-9: 185) who received a RP (ICD-9: 60.5) between 2005 and 2010, excluding men who underwent salvage RP, for a final cohort of 5,082 men. Surgery occurred at civilian hospitals, where revenue is a fee-for-service reimbursement system, or military hospitals, which are supported through federal government appropriations. With description statistics and regression analysis, we assessed yearly utilization of minimally invasive RP, 30-day postoperative complications, preoperative and long-term outcomes. Results: A total of 3,366 men underwent RP in military hospitals compared to 1,716 in civilian hospitals, with minimal clinicodemographic differences between the groups. Overall, adoption of minimally invasive RP in civilian hospitals was 30% greater. There were fewer blood transfusions (OR 0.44) and shorter length of stay (IRR 0.85) among civilian hospitals, while postoperative complications, urinary incontinence and erectile dysfunction were comparable. Conclusions: A fee-for-service reimbursement structure of civilian hospitals was associated with a more rapid adoption of minimally invasive radical prostatectomy but no clinically significant improvement in outcomes. Further studies are needed to determine if changes in the United States healthcare system will impact future development and dissemination of clinical innovation

Radical Prostatectomy Innovation and Outcomes at Military and Civilian Institutions

Objectives: Limited data are available regarding the impact of the type of healthcare delivery system on technology diffusion and associated clinical outcomes. We assessed the adoption of minimally invasive radical prostatectomy (MIRP), a recent clinical innovation, and whether this adoption altered surgical morbidity for prostate cancer surgery. Study Design: Retrospective review of administrative data from TRICARE, the healthcare program of the United States Military Health System. Surgery occurred at military hospitals, supported by federal appropriations, or civilian hospitals, supported by hospital revenue. Methods: We evaluated TRICARE beneficiaries with prostate cancer (International Classification of Disease, 9th Revision, Clinical Modification [ICD-9-CM] code: 185) who received a radical prostatectomy (60.5) between 2005 and 2009. MIRP was identified based on minimally invasive surgery codes (54.21, 17.42). We assessed yearly MIRP utilization, 30-day postoperative complications (Clavien classification system), length of stay, blood transfusion, and long-term urinary incontinence and erectile dysfunction. Results:A total of 3366 men underwent radical prostatectomy at military hospitals compared with 1716 at civilian hospitals, with minimal clinic-demographic differences. MIRP adoption was 30% greater at civilian hospitals. There were fewer blood transfusions (odds ratio, 0.44; P Conclusions: Compared with military hospitals, civilian hospitals had a greater MIRP adoption during this timeframe, but had comparable surgical morbidity

Vorträge des 129. PTB-Seminars am 19./20.3.1996

Am 19./20.03.1996 fand in Braunschweig das 129. PTB-Seminar „Brennwertbestimmung von Gasen im geschäftlichen Verkehr“ statt. 145 Teilnehmer dokumentierten das große Interesse seitens der Gasversorgungsindustrie, der Eichämter und der Gasverbraucher. In 16 Vorträgen wurde der Bogen gespannt von den zur Brennwertbestimmung verwendeten Verfahren (Gaskalorimetrie, Gaschromatographie, Brennwertverfolgungssysteme, digitale Datenübertragung), über deren metrologische Grundlagen (Rückführung von Gasanalysen, Metrologie in der Chemie, primäre Methoden zur Messung der Stoffmenge), die gesetzlichen und normativen Grundlagen und deren zukünftige Entwicklung in der Bundesrepublik bis hin zu einer Vorstellung der in einigen benachbarten europäischen Ländern angewandten Regeln und Gesetze mit einem Überblick über die zukünftige Arbeit der OIML auf diesem Gebiet.PTB-Bericht PTB-ThEx-1, ISBN 3-89701-013-5, ISSN 1434-2391.Vorträge des 129. PTB-Seminars am 19./20.3.199