Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.
OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement. (+info)
Risk-adjusted capitation based on the Diagnostic Cost Group Model: an empirical evaluation with health survey information.
OBJECTIVE: To evaluate the predictive accuracy of the Diagnostic Cost Group (DCG) model using health survey information. DATA SOURCES/STUDY SETTING: Longitudinal data collected for a sample of members of a Dutch sickness fund. In the Netherlands the sickness funds provide compulsory health insurance coverage for the 60 percent of the population in the lowest income brackets. STUDY DESIGN: A demographic model and DCG capitation models are estimated by means of ordinary least squares, with an individual's annual healthcare expenditures in 1994 as the dependent variable. For subgroups based on health survey information, costs predicted by the models are compared with actual costs. Using stepwise regression procedures a subset of relevant survey variables that could improve the predictive accuracy of the three-year DCG model was identified. Capitation models were extended with these variables. DATA COLLECTION/EXTRACTION METHODS: For the empirical analysis, panel data of sickness fund members were used that contained demographic information, annual healthcare expenditures, and diagnostic information from hospitalizations for each member. In 1993, a mailed health survey was conducted among a random sample of 15,000 persons in the panel data set, with a 70 percent response rate. PRINCIPAL FINDINGS: The predictive accuracy of the demographic model improves when it is extended with diagnostic information from prior hospitalizations (DCGs). A subset of survey variables further improves the predictive accuracy of the DCG capitation models. The predictable profits and losses based on survey information for the DCG models are smaller than for the demographic model. Most persons with predictable losses based on health survey information were not hospitalized in the preceding year. CONCLUSIONS: The use of diagnostic information from prior hospitalizations is a promising option for improving the demographic capitation payment formula. This study suggests that diagnostic information from outpatient utilization is complementary to DCGs in predicting future costs. (+info)
Why do patients seek family physicians' services for cold symptoms?
OBJECTIVE: To examine the frequency of presentation to family physicians' offices for cold symptoms, the reasons for presentation, and the duration of symptoms before presentation. DESIGN: Prospective cross-sectional survey. PARTICIPANTS: One hundred consecutive patient encounters in each of 15 family practices from January 27 to February 3, 1994, involving both academic and non-academic family physicians in the London region. Data were collected prospectively using a checklist attached to each chart. MAIN OUTCOME MEASURES: Proportion of patients presenting with cold symptoms, reasons for presentation, number of days patients had had symptoms, billing code. RESULTS: A total of 1421 checklists were analyzed, 822 from academic practices and 599 from community practices. Proportion of presentations for cold symptoms was 14.8%, but visits coded as common cold represented 5.7%. Median number of days patients waited before presentation was 7.0; older patients tended to wait longer. Many patients were worried about developing complications (51.0%) or were fed up with their symptoms (31.9%). Most patients were between the ages of 20 and 64 (44.6%), and 57.6% of all patients had developed complications requiring treatment. CONCLUSIONS: The proportion of visits coded as common cold was lower than Ontario averages. Most patients had complications rather than simple colds and had managed their symptoms on their own for a fairly long time. (+info)
Saturday night fever? Reasons for referral from health centres to hospitals during weekends in Finland.
OBJECTIVE: We aimed to examine the reasons for referral from health centres to hospitals during the weekend in Finland. METHOD: We conducted a survey of all referrals from general practice on two weekends (30 November to 6 December 1992 and 28 November to 4 December 1994) in central and northern Finland, which covered 72% of the area of the country and one-third of the population. The participants were 178 GPs from public health centres and who made 530 referrals during these weekends. The outcome measures were reasons for referrals by ICPC codes with respect to the characteristics of patients, GPs and practices. RESULTS: During the weekends studied, 530 patients were referred from out-of-hours work. More male (53%) than female patients (47%) were referred. Out of a total of 530 patients, 213 (40%) were referred to surgery, 139 (26%) to internal medicine, 48 (9%) paediatric medicine, 32 (6%) to neurology, 28 (5%) to both ear, nose and throat (ENT) and psychiatry, 25 (5%) to gynaecology and 18 (4%) to other specialities (ophthalmology, lung disease and cancer departments). Fractures requiring surgery, angina pectoris for which patients were sent to internal medicine and stroke for which patients were sent to other specialities were the most commonly reported reasons for referral. Male patients were referred 12 times more often than females for arrhythmia (atrial fibrillation or tachyarrhythmia); males experienced dislocations eight times more often and fractures three times more often than females. CONCLUSION: Our results point out the need to train GPs about those complaints that most often require a referral to specialist care during the weekend. Future research should focus on those patients who are responsible for the huge gender gap of reasons for referral during weekends. (+info)
House calls in Lebanon: reflections on personal experience.
BACKGROUND: Home health services play an important role in decreasing hospital admissions and physicians' medical house calls play an integral role in home health services. There is no national survey of physicians' house call practice in the Lebanon. OBJECTIVES: The aim of this study was to provide some information about house call practice in the Lebanon. METHOD: Data on patients examined during house call visits between 1 January and the end of December 1995 were reviewed. RESULTS: During this period, 137 patients were seen at their home. Eighty-four patients (62%) were female and 53 patients (38%) were male. Ages ranged from 1 to 85 years. The number of cases seen in 1 month averaged 11. The diagnosis differed according to the age group of patients examined. Most of the house call visits occurred between 6.30 p.m. to 12.00 p.m. (47%). Fifteen patients (11%) were admitted to the hospital. CONCLUSION: The rate of cases per month was similar to those reported elsewhere. Physicians might feel reluctant to conduct house calls out of hours. Our study revealed that the majority of patients were seen between 6 p.m. and 12 p.m., and only 6% were seen after 12 a.m. It is our belief that house calls are an integral part of family practice and need to be stressed during the internships of all primary care physicians. (+info)
A program to reduce discharge delays in a neonatal intensive care unit.
Our hypothesis was that a program designed to identify the causes of discharge delays would reduce the length of stay in our neonatal intensive care unit. We reviewed every admission from January, 1994, to December, 1995. A discharge delay was defined as any delay not related to illness after the infant was cleared for release. Discharge delays were divided into the following categories: primary healthcare team, organizational, discharge planning, family, monitor related, and other. Potential discharge delays were identified daily according to established criteria. Actual discharge delays were reviewed monthly at a staff meeting attended by representatives of a multidisciplinary team. We identified 116 discharge delays, which accounted for 480 patient days. Eighty-three discharge delays accounted for 302 patient days in 1994, and 33 discharge delays for 178 patient days in 1995. Discharge delays ranged from 1 to 34 days, with an average of 4.1 days added per patient. Infants with discharge delays had a case mix index of 9.32. The average case mix index for the neonatal intensive care unit was 6.25 during 1994 and 5.18 during 1995, an average of 5.71 for the review period. Forty-four percent of infants who had discharge delays had private insurance, 55% had Medicaid, and 1% had self-payment arrangements. Eighty-eight of 116 discharge delays were caused by circumstances beyond the control of the primary care team. An additional 25 of 116 discharge delays were the result of our policy requiring 48 hours free of apnea-bradycardia alarms before discharge. Discharge delays for 1994 cost $226,298 ($749/day). For 1995, discharge delays cost $41,553 ($233/day) for a total cost of $262,431. Total savings in 1995 versus 1994 was $184,745 ($516/day). Despite the low birth weight and relatively severe illnesses of the infants, we believe that a focused team approach and monitoring for potential discharge delays can result in considerable reduction in hospital stay and cost. (+info)
The impact of reimbursement changes for intracoronary stents on providers and Medicare.
CONTEXT: New Medicare reimbursement policies will move stents into a different diagnosis-related group (DRG) than conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). OBJECTIVE: To examine the financial impact on hospitals and Medicare of these planned changes, taking into account costs, reimbursement, and the cost-offset effect of prevented complications. DESIGN: The economic impact of proposed reimbursement changes was modeled by using a retrospective clinical and economic data set from a single institution. PATIENTS AND METHODS: A total of 421 consecutive interventional cases from 1996 were examined by using actual cost data. The new, proposed revenues were assigned to these cases. From the hospitals' perspective, the focus was on contribution margin (the difference between revenues and costs), risk adjusted for case-mix severity. From Medicare's perspective, the focus was on expenditures. Various assumptions were adopted for two clinical variables: the effectiveness of stents in preventing the major PTCA-related complications of myocardial infarction and coronary artery bypass graft surgery and the relative proportions of myocardial infarction and coronary artery bypass graft surgery in the mix of complications. Under current Medicare DRG policies, coronary artery bypass graft surgery is highly profitable for hospitals, whereas myocardial infarction as a complication of PTCA has a negative financial impact. RESULTS: Under the new Medicare reimbursement policies, hospitals experience higher profitability with stents than with conventional PTCA under most assumed levels of clinical effectiveness and mixes of myocardial infarction and coronary artery bypass graft surgery. For Medicare, under most circumstances (including percentages of stent use and levels of clinical effectiveness that represent contemporary practice) stents lead to greater expenditures. CONCLUSIONS: Medicare reimbursement changes will substantially realign previously misaligned financial and clinical incentives for hospitals. The immediate effect on hospitals will be to enhance profitability, whereas the effect on Medicare will be to increase expenditures. (+info)
Public hospital resource allocations in El Salvador: accounting for the case mix of patients.
National hospitals in developing countries command a disproportionate share of medical care budgets, justified on the grounds that they have a more difficult patient case mix and higher occupancy rates than decentralized district hospitals or clinics. This paper empirically tests the hypothesis by developing direct measures of the severity of patient illness, hospital case-mix and a resource intensity index for each of El Salvador's public hospitals. Based on an analysis of inpatient care staffing requirements, national hospitals are found to receive funding far in excess of what case-mix and case-load considerations would warrant. The findings suggest that significant system-wide efficiency gains can be realized by allocating hospital budgets on the bases of performance-related criteria which incorporate the case-mix approach developed here. (+info)