The economics of clinical genetics services. II. A time analysis of a medical genetics clinic.

In a time-and-reimbursement analysis of our clinical genetics service, we documented (1) the time spent by professionals and staff in serving families before, during, and after the clinic visit; (2) the charges and reimbursement for the services provided; and (3) the relationship between income from clinical practice and the personnel costs of the clinic. We found that newly referred and returning families required 7.1 and 4.0 h, respectively. Average collections for professional services were +135 (+19/h) for new families and +49 (+12/h) for returning families. Income from clinical practice covered 37% of the clinical portion of personnel costs. These results indicate that cognitive clinical genetics services are labor intensive, yield low payments per service hour, and are not financially self-supporting. To improve the economic status of genetics clinics, administrators might consider rendering services more efficiently; increasing charges for services; billing for all services provided to all family members; billing for all genetics professionals, including counselors and social workers; and requesting payment at the time of service.     

The economics of clinical genetics services. IV. Financial impact of outpatient genetic services on an academic institution.

Those clinical genetic services that do not involve laboratory tests or procedures--i.e., the "cognitive" services such as diagnosis, management, and counseling--are labor-intensive, time-consuming, and not self-supporting. However, as a result of an evaluation at a genetics clinics, a patient will often receive other services at the same medical center. The full economic impact of the genetics clinic may be underappreciated. Therefore, at one medical center we examined (a) three settings that delivered genetics services and (b) two specialty clinics providing services to children with genetics conditions; and we calculated charges and payments for an unselected, consecutive group of outpatients. The results showed that cognitive genetics services accounted for a variable, but generally low, percentage of both the professional (generally physicians') and total charges accumulated by patients as a consequence of their visit to the genetics clinic. With laboratory and procedural charges included, patients seen in general genetics clinics (or their insurance plans) paid up to three times as much to the medical center and to its health professionals as to the genetics professional. These data confirm that clinical genetics services, while not generating enough income to cover their own costs, bring considerable revenue to the medical center. This fact alone should prove useful to the director of clinical genetics programs when they are negotiating finances with institutional administrators.     

The economics of clinical genetics services. I. Preview.

To an ever increasing extent, a variety of economic factors are affecting the delivery of clinical genetics services. These economic factors, which we enumerate with an historical perspective, influence how genetics professionals, patients, and third-party payers relate to genetics services. From the perspectives of each of these interested parties, the deficiency of objective information about the current economic situation is striking. The recent history of charges and reimbursement for our genetics clinic illustrates both one kind of data that is readily available and how modification of administrative procedures can improve the economic balance sheet. However, several characteristics of clinical genetics limit the possibility of economic self-sufficiency.     

Delivery of molecular genetic services within a health care system: time analysis of the clinical workload. The Molecular Genetic Study Group.

The most recent discoveries in molecular genetics today are rapidly incorporated into clinical practice and have resulted in an unprecedented expansion of medical options. Despite this, the impact of molecular genetics on health care services has yet to be evaluated. In order to begin this assessment, clinical genetic workload was prospectively collected from cases where molecular genetic testing was considered. Participation involved all 16 urban and outreach genetic centers regionalized to service the entire population of 10 million within the Canadian province of Ontario. Molecular genetic testing has been clinically available for > 5 years, as part of a publicly supported genetic network in which there are no direct costs to residents. Cross-sectional data were collected on 1,101 clients from 544 families involving 1,742 clinical actions relating to diseases in which molecular (DNA) tests were considered. Median times per clinical genetic action were as follows: formal counseling (60 min), case review (15 min), phone call (10 min), letter (15 min), specimen arrangement (15 min), and interpretation of molecular test results (10 min). Times varied significantly with the inheritance pattern of the disease, topics involved, and location. For any given genetic case, multiple clinical actions resulted in substantial time spent by the genetic professional. Clerical and administrative times were not captured. Workload unit measurements similar to those currently employed in hospital laboratories may be helpful for predicting the clinical resources and personnel that will be required as the use of molecular genetics by other medical specialties increases.     

Knowledge of genetics among residents in obstetrics and gynecology.

A supervised genetics examination was administered to 76 obstetrics and gynecology (ob/gyn) residents from 15 different institutions in the Philadelphia area. The questions were specifically designed to be applicable to obstetrical practice. Overall, the mean score was 69% (range 32%-88%). Using the nonparametric Mann-Whitney rank sum test, we found that the 25 residents from institutions with an obstetrics-gynecology-genetics (OGG) program, coordinated by an obstetrician/gynecologist board certified in clinical genetics, had statistically significant higher scores than the remaining 51 residents from institutions without an OGG program (77% vs. 65%, respectively; P < .001). This study demonstrates that knowledge of genetics among residents in ob/gyn is deficient, especially among residents at institutions without OGG programs. Special efforts should be made to provide genetics education to these individuals. We propose that more obstetricians be encouraged to pursue postgraduate training in genetics in light of the rapid development of medical genetics; its application to prenatal screening, diagnosis, and counseling; the anticipated utilization of genetics services; and the need for educational initiatives geared toward ob/gyn patients.     

Education of nurses in genetics.

The need for education of nurses in genetics was articulated more than 25 years ago. This article reviews the knowledge of practicing nurses about genetics as well as the content of genetics in nursing curricula. Implementation of federal legislation that mandated increased availability of genetic services and genetics education provided support for the examination of genetics content in curricula for health professionals, including nurses, and for the development of model programs to expand this content. Recent efforts to begin to develop a pool of nurse faculty who are well prepared in genetics will be described, as well as programs to provide the necessary content through continuing-education efforts. These efforts are expected to substantially improve the capability of nurses to contribute more effectively in the delivery of genetic services.     

Teenage sexual behaviour: perceptive and behavioural outcomes associated with receipt of family planning services.

The validity of the fear that providing teen-age girls with family planning information and services will lead to promiscuity is examined. Changes in self-perception of the levels of sexual activity of unmarried, sexually active teen-age girls and changes in the frequency of sexual intercourse and number of sexual partners following attendance at a family planning clinic were evaluated among 71 teen-age girls. All 71 girls, aged between 13 and 18, had had sexual intercourse and were never married. 79% of the girls had had their 1st intercourse 1 or more years before their 1st attendance at a "rap" session. Only 21% had had 1st intercourse less than 1 year before attending. 61 of these girls later received contraceptive services at the clinic (clinic group) and their behavior was compared at follow-up with that of the 10 girls who did not attend the clinic again (non-clinic group). The mean frequency of sexual intercourse of the clinic group increased after receiving contraceptive services but did not differ significantly from the figure for the non-clinic group. 89% of the clinic group, after receipt of contraceptive services, restricted their sexual activity to 1 partner. This study calls into question the basis of some fears regarding the provision of family planning services to sexually active teen-age girls.     

State-of-the-art biomolecular core facilities: a comprehensive survey

A survey of 124 protein and/or nucleic acid chemistry facilities has provided a basis for estimating the resources needed to establish a facility, the financial support needed to keep it operating, and the technical capabilities it might reasonably be expected to achieve. Based on these data, an average core facility occupied 870 ft2, was staffed by three full-time personnel, and was equipped with 4-5 major instrument systems. Because user fees generated an average of about $101,000/year in income compared with an average operating budget of about $197,000/year, even a facility that charged user fees would, on average, still require an annual subsidy of about $96,000. Although most government and industrial core facilities did not assess user fees, at least 83 of the 124 respondents did have a preestablished schedule of service charges that enabled a compilation to be made of the average cost of providing a number of typical facility analyses and syntheses. The greater than 100-fold range in charges assessed in core facilities for seemingly identical services was shown to result from the equally large range in the degree of subsidization of these laboratories. Although an average facility might be expected to offer four or five of the following six major services--amino acid sequencing, amino acid analysis, HPLC peptide isolation, peptide synthesis, fragmentation of proteins and DNA synthesis--less than 10% of the responding laboratories provided mass spectrometry, capillary zone electrophoresis, or RNA synthesis. With the exception of peptide synthesis, which had an average turn-around time of about 24 days, all other major services had turn-around times that averaged in the range of 4-9 days. Additional data are summarized regarding average sample throughput in core laboratories and the amount of protein that is needed for hydrolysis/amino acid analysis and sequencing.     

Cost of primary health care services in the emergency department and the family physician's office.

An attempt has been made to determine the true cost of providing primary health care for nontraumatic conditions in the emergency departments of two hospitals in Ontario and in the offices of family physicians. A total of 1117 patients presenting with 1 of 10 common symptom/sign complexes at the emergency departments or the offices of 15 participating family physicians were studies with regard to number of visits made, type of assessment by the physician, investigations undertaken, management, therapy and outcome of the illness. Costs were calculated from the charges that would be made against the provincial health services insurance plan and from the system of hospital financing in effect in the province. The average true cost per illness episode of this type of care was $14.63 in hospital A, $14.20 in hospital B and $15.90 in the family physician''s office.     

Human genetics teaching in U.S. medical schools.

Information about instruction in genetics was obtained fron 103 of the 107 U.S. four-year medical schools. Seventy-two percent of the schools provide a compulsory course in genetics, but there was great variation in duration, content, departmental responsibility for giving the course, and in the disciplines of those doing the teaching. The variability in the number of hours devoted to teaching genetics was reflected in the competence of the students in giving correct answers to questions on genetics posed by the National Board of Medical Examiners. Electives and continuing education courses on genetics are given by two-thirds and one-half of the schools, respectively; but the subject receives very little attention in departments of preventive, community, or family medicine or in schools of allied health sciences. These findings suggest that genetics has not yet found a natural and comfortable context in the curricula of U.S. medical schools.     

Cost of allogeneic and autologous blood transfusion in Canada. Canadian Cost of Transfusion Study Group.

OBJECTIVE: To determine the cost, from a societal perspective, of blood transfusion in Canada. STUDY DESIGN: Cost-structure analysis. SETTING: Data were collected from eight hospitals and from six blood centres operated by the Canadian Red Cross Society in four provinces. OUTCOME MEASURES: Costs associated with four stages of transfusion-- collection, production, distribution and delivery--in 1933 were assessed. Costs were divided into the following categories; personnel, purchases, external services, overhead, donors'' time, patients'' time (for autologous transfusion), wastage and infection. RESULTS: The mean overall cost of a transfusion performed on an inpatient basis was $210 per unit of red blood cells for an allogeneic transfusion and $338 per unit of blood for an autologous transfusion. The mean cost of an allogeneic transfusion performed on an outpatient basis was $280 per unit of red blood cells. CONCLUSION: The costs determined in this study can be used in future studies comparing the cost-effectiveness of allogeneic transfusion with that of alternative methods.     

A Cross-Sectional Analysis of Variation in Charges and Prices across California for Percutaneous Coronary Intervention

Background

Though past studies have shown wide variation in aggregate hospital price indices and specific procedures, few have documented or explained such variation for distinct and common episodes of care.

Objectives

We sought to examine the variability in charges for percutaneous coronary intervention (PCI) with a drug-eluting stent and without major complications (MS-DRG-247), and determine whether hospital and market characteristics influenced these charges.

Methods

We conducted a cross-sectional analysis of adults admitted to California hospitals in 2011 for MS-DRG-247 using patient discharge data from the California Office of Statewide Health Planning and Development. We used a two-part linear regression model to first estimate hospital-specific charges adjusted for patient characteristics, and then examine whether the between-hospital variation in those estimated charges was explained by hospital and market characteristics.

Results

Adjusted charges for the average California patient admitted for uncomplicated PCI ranged from $22,047 to $165,386 (median: $88,350) depending on which hospital the patient visited. Hospitals in areas with the highest cost of living, those in rural areas, and those with more Medicare patients had higher charges, while government-owned hospitals charged less. Overall, our model explained 43% of the variation in adjusted charges. Estimated discounted prices paid by private insurers ranged from $3,421 to $80,903 (median: $28,571).

Conclusions

Charges and estimated discounted prices vary widely between hospitals for the average California patient undergoing PCI without major complications, a common and relatively homogeneous episode of care. Though observable hospital characteristics account for some of this variation, the majority remains unexplained.     

Use of hospital services by homeless families in an inner London health district.

Over the past decade the number of families in London who were considered officially to be homeless appreciably increased. In response to this many families have been given temporary accommodation, usually in bed and breakfast hotels, while awaiting permanent rehousing. About 200 of the roughly 600 hotels in London that provide such accommodation are located in the area of the former Paddington and North Kensington Health Authority, now part of Parkside Health Authority. The use made by the homeless population of hospital services was studied by finding out the numbers of inpatients admitted to hospital and the numbers presenting to the walk in paediatric clinic and the casualty department at one hospital. These figures were compared with those for local residents and the overall workload. The bed and breakfast population were high users of inpatient beds, the casualty department, and the paediatric clinic. Overall, about one tenth of the beds were used by these people. The health authority receives no additional funding for this group of patients. Further research is needed to find out if the high use of hospital services made by these patients reflects their increased morbidity or their inability to obtain primary care services.     

Cost Evaluation of Reproductive and Primary Health Care Mobile Service Delivery for Women in Two Rural Districts in South Africa

Background

Cervical cancer screening is a critical health service that is often unavailable to women in under-resourced settings. In order to expand access to this and other reproductive and primary health care services, a South African non-governmental organization established a van-based mobile clinic in two rural districts in South Africa. To inform policy and budgeting, we conducted a cost evaluation of this service delivery model.

Methods

The evaluation was retrospective (October 2012–September 2013 for one district and April–September 2013 for the second district) and conducted from a provider cost perspective. Services evaluated included cervical cancer screening, HIV counselling and testing, syndromic management of sexually transmitted infections (STIs), breast exams, provision of condoms, contraceptives, and general health education. Fixed costs, including vehicle purchase and conversion, equipment, operating costs and mobile clinic staffing, were collected from program records and public sector pricing information. The number of women accessing different services was multiplied by ingredients-based variable costs, reflecting the consumables required. All costs are reported in 2013 USD.

Results

Fixed costs accounted for most of the total annual costs of the mobile clinics (85% and 94% for the two districts); the largest contributor to annual fixed costs was staff salaries. Average costs per patient were driven by the total number of patients seen, at $46.09 and $76.03 for the two districts. Variable costs for Pap smears were higher than for other services provided, and some services, such as breast exams and STI and tuberculosis symptoms screening, had no marginal cost.

Conclusions

Staffing costs are the largest component of providing mobile health services to rural communities. Yet, in remote areas where patient volumes do not exceed nursing staff capacity, incorporating multiple services within a cervical cancer screening program is an approach to potentially expand access to health care without added costs.     

On the genetics of prelingual deafness.

In view of the many discordant findings in previous studies regarding the genetics of prelingual deafness, family data (133 nuclear families and 25 pedigrees) were gathered from India. Analysis of these data has revealed that the defect is primarily genetic, which is in agreement with earlier findings. Segregation analysis was performed to compare various autosomal diallelic one-locus and multilocus models. Our analysis revealed that the most parsimonious model for prelingual deafness is that it is controlled by recessive genes at a pair of unlinked diallelic autosomal loci. Individuals are affected if and only if they are recessive homozygous at both loci. The likelihood of the present data under this two-locus multiple recessive homozygosis model is at least 10(8) times higher than that of the one-locus models that were examined in previous studies. This model is also the best-fitting model among other plausible two-locus models.     

Human behavioural genetics of cognitive abilities and disabilities

Although neither the genome nor the environment can be manipulated in research on human behaviour, some of the new tools of molecular genetics can be brought to bear on human behavioural disorders (e.g. cognitive disabilities) and quantitative traits (e.g. cognitive abilities). The inability to manipulate the human genome experimentally has had the positive effect of focusing attention on naturally occuring genetic variation responsible for behavioural differences among individuals in all their complex multifactorial splendour. Genes in such complex multiple-gene systems are called quantitative trait loci (QTLs), which merge the two worlds of genetic research, quantitative genetics and molecular genetics. Although most genetic research on complex human behaviour has focused on severe mental disorders, cognitive abilities and disabilities may be even more immediately relevant to neuroscience. For example, verbal ability and spatial ability are two of the most heritable cognitive abilities, and reading disability is the first behavioural disability for which replicated QTL linkage has been found. The purpose of this essay is to provide an overview of the genetics of cognitive abilities and disabilities as an example of the impending merger of quantitative genetics and molecular genetics in QTL analysis of complex traits.     

Charges for comprehensive obstetric care at teaching and nonteaching hospitals. A comparison.

We compared total charges for obstetric care at a major teaching hospital and faculty group practice with those at 3 nonteaching centers in western Washington. The patients were all enrollees of an employee-based health maintenance organization. Charges were used as a proxy for costs and included all outpatient, inpatient, and physician charges. In the teaching system, patients were cared for by faculty and house staff; in the nonteaching settings, they received care from private physicians. No significant differences in total charges were found between the teaching and the nonteaching settings for all deliveries ($4,652 [N = 90] versus $4,530 [N = 335], P greater than .5). In the teaching setting, vaginal deliveries were slightly more expensive ($4,178 [n = 75] versus $3,768 [n = 250], P = .15), as were cesarean deliveries ($7,024 [n = 15] versus $6,771 [n = 85], P greater than .5). The rate of cesarean deliveries was lower in the teaching setting (17% versus 25%, P = .10), partially accounting for the similarity in total charges. The length of stay was similar in the teaching hospital (3.29 versus 3.14 days, P greater than .5). We conclude that the academic medical center as a total system of care can provide obstetric care as cost-effectively as nonteaching systems under the constraints of prepaid care.     

Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria

Objective

There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups.

Methods

The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care.

Results

The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme.

Conclusion

The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms.