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Impact of eligibility criteria on phototherapy program size and cost
R Plastino1, D M Buchner, E H Wagner
1General Internal Medicine Section, Virginia Mason Clinic, Seattle, WA 98111.
Insights
Eligibility criteria significantly impact phototherapy program size and cost. Modest variations in standards of care can lead to substantial differences in medical costs for infant jaundice treatment.
Area of Science:
- Neonatal care
- Health economics
- Public health policy
Background:
- Infant jaundice is common, often requiring phototherapy.
- Phototherapy protocols vary, potentially affecting program costs.
- Health Maintenance Organizations (HMOs) aim to manage healthcare costs.
Purpose of the Study:
- To assess how different eligibility criteria influence phototherapy program size and associated costs.
- To compare the impact of the American Academy of Pediatrics (AAP) criteria versus HMO-specific criteria.
- To analyze cost-saving mechanisms within HMOs related to phototherapy.
Main Methods:
- Prospective study of 786 births within a large HMO.
- Comparison of four distinct sets of phototherapy eligibility criteria.
- Analysis of indicated treatments, home vs. hospital care, and estimated annual costs.
Main Results:
- Treatment indications varied significantly based on criteria, affecting 10.9% of infants.
- The percentage of infants receiving phototherapy ranged from 14% to 100% depending on the criteria used.
- Estimated annual discretionary phototherapy costs varied widely, from $15,168 to $90,800, primarily due to the number of infants treated.
Conclusions:
- Small changes in phototherapy eligibility criteria can disproportionately affect medical care costs.
- HMO cost savings in phototherapy were mainly achieved by reducing the number of infants treated, not solely by shifting care to outpatient settings.
- Standardizing criteria is crucial for managing phototherapy program size and expenditure effectively.
Abstract:
To determine the effect of eligibility criteria on phototherapy program size and cost, 786 births in a large Health Maintenance Organization were prospectively studied. Four sets of criteria were compared, including those of the American Academy of Pediatrics and the health maintenance organization's own criteria. With all criteria sets, hospital-based phototherapy treatment was indicated for 13 (1.7%) infants and no phototherapy was indicated for 687 (87.4%) infants. Treatment varied substantially according to criteria set for the remaining 86 (10.9%) infants. From 14% to 100% of these infants would have received treatment, depending on the criteria applied; of those potentially treated, from 30% to 80% would have received home treatment. Estimated annual discretionary phototherapy costs (1985 dollars) ranged from $15,168 with the health maintenance organization criteria to almost five to six times this amount ($70,232 to $90,800) with the other criteria. Differences in costs were due mainly to the number of infants treated. This study illustrates the way in which modest variation in standards of care can potentially have a relatively large effect on medical care costs. As a case study of how health maintenance organizations reduce costs, the study shows that although the health maintenance organization anticipated costs savings due to substituting outpatient care for hospital care, most savings occurred because of a reduction in the number of infants treated.