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)
Incidence and duration of hospitalizations among persons with AIDS: an event history approach.
OBJECTIVE: To analyze hospitalization patterns of persons with AIDS (PWAs) in a multi-state/multi-episode continuous time duration framework. DATA SOURCES: PWAs on Medicaid identified through a match between the state's AIDS Registry and Medicaid eligibility files; hospital admission and discharge dates identified through Medicaid claims. STUDY DESIGN: Using a Weibull event history framework, we model the hazard of transition between hospitalized and community spells, incorporating the competing risk of death in each of these states. Simulations are used to translate these parameters into readily interpretable estimates of length of stay, the probability that a hospitalization will end in death, and the probability that a nonhospitalized person will be hospitalized within 90 days. PRINCIPAL FINDINGS: In multivariate analyses, participation in a Medicaid waiver program offering case management and home care was associated with hospital stays 1.3 days shorter than for nonparticipants. African American race and Hispanic ethnicity were associated with hospital stays 1.2 days and 1.0 day longer than for non-Hispanic whites; African Americans also experienced more frequent hospital admissions. Residents of the high-HIV-prevalence area of the state had more frequent admissions and stays two days longer than those residing elsewhere in the state. Older PWAs experienced less frequent hospital admissions but longer stays, with hospitalizations of 55-year-olds lasting 8.25 days longer than those of 25-year-olds. CONCLUSIONS: Much socioeconomic and geographic variability exists both in the incidence and in the duration of hospitalization among persons with AIDS in New Jersey. Event history analysis provides a useful statistical framework for analysis of these variations, deals appropriately with data in which duration of observation varies from individual to individual, and permits the competing risk of death to be incorporated into the model. Transition models of this type have broad applicability in modeling the risk and duration of hospitalization in chronic illnesses. (+info)
Making Medicaid managed care research relevant.
OBJECTIVE: To help researchers better understand Medicaid managed care and the kinds of research studies that will be both feasible and of value to policymakers and program staff. The article builds on our experience researching Medicaid managed care to provide insight for researchers who want to be policy relevant. PRINCIPAL FINDINGS: We draw four lessons from our work on Medicaid managed care in seven states. First, these are complex programs that differ substantially across states. Second, each program faces common challenges and issues. The need to address common design elements involving program eligibility, managed care and provider contracting, beneficiary enrollment, education, marketing, and administration and oversight provides a vehicle that researchers can use to help understand states and to provide them with relevant insight. Third, well-designed case studies can provide invaluable descriptive insights. Such case studies suggest that providing effective descriptions of state programs and experience, monitoring information on program performance and tradeoffs, and insight on implementation and design are all valuable products of such studies that have considerable potential to be converted into policy-actionable advice. And fourth, some questions demand impact studies but the structure of Medicaid managed care poses major barriers to such studies. CONCLUSIONS: Many challenges confront researchers seeking to develop policy-relevant research on managed care. Researchers need to confront these challenges in turn by developing second-best approaches that will provide timely insight into important questions in a relatively defensible and rigorous way in the face of many constraints. If researchers do not, others will, and researchers may find their contributions limited in important areas for policy debate. (+info)
A taxonomy of health networks and systems: bringing order out of chaos.
OBJECTIVE: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features. DATA SOURCES: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems. STUDY DESIGN: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations. These dimensions were applied to three components of the health service/product continuum: hospital services, physician arrangements, and provider-based insurance activities. DATA EXTRACTION METHODS: We identified 295 health systems and 274 health networks across the United States in 1994, and 297 health systems and 306 health networks in 1995 using AHA data. Empirical measures aggregated individual hospital data to the health network and system level. PRINCIPAL FINDINGS: We identified a reliable, internally valid, and stable four-cluster solution for health networks and a five-cluster solution for health systems. We found that differentiation and centralization were particularly important in distinguishing unique clusters of organizations. High differentiation typically occurred with low centralization, which suggests that a broader scope of activity is more difficult to centrally coordinate. Integration was also important, but we found that health networks and systems typically engaged in both ownership-based and contractual-based integration or they were not integrated at all. CONCLUSIONS: Overall, we were able to classify approximately 70 percent of hospital-led health networks and 90 percent of hospital-led health systems into well-defined organizational clusters. Given the widespread perception that organizational change in healthcare has been chaotic, our research suggests that important and meaningful similarities exist across many evolving organizations. The resulting taxonomy provides a new lexicon for researchers, policymakers, and healthcare executives for characterizing key strategic and structural features of evolving organizations. The taxonomy also provides a framework for future inquiry about the relationships between organizational strategy, structure, and performance, and for assessing policy issues, such as Medicare Provider Sponsored Organizations, antitrust, and insurance regulation. (+info)
Organizational and environmental factors associated with nursing home participation in managed care.
OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services. (+info)
Explicit guidelines for qualitative research: a step in the right direction, a defence of the 'soft' option, or a form of sociological imperialism?
Within the context of health service research, qualitative research has sometimes been seen as a 'soft' approach, lacking scientific rigour. In order to promote the legitimacy of using qualitative methodology in this field, numerous social scientists have produced checklists, guidelines or manuals for researchers to follow when conducting and writing up qualitative work. However, those working in the health service should be aware that social scientists are not all in agreement about the way in which qualitative work should be conducted, and they should not be discouraged from conducting qualitative research simply because they do not possess certain technical skills or extensive training in sociology, anthropology or psychology. The proliferation of guidelines and checklists may be off-putting to people who want to undertake this sort of research, and they may also make it even more difficult for researchers to publish work in medical journals. Consequently, the very people who may be in a position to change medical practice may never read the results of important qualitative research. (+info)
The future of managed care organization.
This paper analyzes the transformation of the central organization in the managed care system: the multiproduct, multimarket health plan. It examines vertical disintegration, the shift from ownership to contractual linkages between plans and provider organizations, and horizontal integration--the consolidation of erstwhile indemnity carriers, Blue Cross plans, health maintenance organizations (HMOs), and specialty networks. Health care consumers differ widely in their preferences and willingness to pay for particular products and network characteristics, while providers differ widely in their willingness to adopt particular organization and financing structures. This heterogeneity creates an enduring role for health plans that are diversified into multiple networks, benefit products, distribution channels, and geographic regions. Diversification now is driving health plans toward being national, full-service corporations and away from being local, single-product organizations linked to particular providers and selling to particular consumer niches. (+info)
Commercialization of BRCA1/2 testing: practitioner awareness and use of a new genetic test.
It was our purpose to determine the characteristics of practitioners in the United States who were among the first to inquire about and use the BRCA1 and BRCA2 (BRCA1/2) genetic tests outside of a research protocol. Questionnaires were mailed to all practitioners who requested information on or ordered a BRCA1/2 test from the University of Pennsylvania (UPenn) Genetic Diagnostics Laboratory (GDL) between October 1, 1995 and January 1, 1997 (the first 15 months the test was available for clinical use). The response rate was 67% of practitioners; 54% (121/225) were genetic counselors, 39% (87/225) were physicians or lab directors. Most physicians were oncologists, pathologists, or obstetrician/gynecologists, but 20% practiced surgery or internal or general medicine. Fifty-six percent (125/225) had ordered a BRCA1/2 test for a patient; most of the rest had offered or were willing to offer testing. Of those who had offered testing, 70% had a patient decline BRCA1/2 testing when offered. Practitioners perceived that patients' fear of loss of confidentiality was a major reason for declining. Nearly 60% of practitioners reported that their patients had access to a genetic counselor, but 28% of physicians who ordered a BRCA1/2 test reported having no such access, despite the GDL's counseling requirement. The proportion of physicians reporting no access to genetic counselors for their patients increased from 22.4% in the first half of the study to 50% in the last half. Many practitioners have an interest in BRCA1/2 testing, despite policy statements that discourage its use outside of research protocols. Practitioner responses suggest that patient interest in testing seems to be tempered by knowledge of potential risks. An apparent increase in patient concern about confidentiality and inability to pay for testing could indicate growing barriers to testing. Although most practitioners reported having access to counseling facilities, perceived lack of such access among an increasing proportion of practitioners indicates that lab requirements for counseling are difficult to enforce and suggests that an increasing proportion of patients may not be getting access to counseling. (+info)