Diagnosis-related Groups and Hospital Inpatient Federal Reimbursement.

To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years.

The epidemiology of syphilis in pregnancy.

This study evaluated the magnitude, risk factors and outcomes of syphilis in pregnancy in a large cohort of women in four countries participating in the World Health Organization (WHO) antenatal care trial. All women attending the first prenatal care at each selected clinic were enrolled. Screening at the first antenatal visit was routinely performed with either rapid plasma reagin or Venereal Disease Research Laboratory and confirmed by fluorescent treponemal antibody absorption. All women also had the same syphilis tests after delivery. The initial prevalence, the incidence during pregnancy and the overall prevalence of syphilis at delivery were 0.9%, 0.4% and 1.3% respectively. Risk factors for syphilis during pregnancy were younger age for the incidence and older age and a history of stillbirth for the prevalence. Women with syphilis during pregnancy had significantly more adverse outcomes. We support the recommendation that in addition to the initial testing, a second routine test for syphilis ought to be established early in the third trimester even in low prevalence areas.

Long-term ophthalmic outcome of low birth weight children with and without retinopathy of prematurity.

OBJECTIVE: A prospective study of retinopathy of prematurity (ROP) of 505 infants who weighed <1701 g at birth was undertaken in the mid-1980s. This cohort was traced at 10 to 12 years of age to determine how low birth weight alone and ROP might influence their ophthalmic outcome. METHODS: Outcome measures were 1) visual functions (visual acuity, contrast sensitivity, stereoacuity, perimetry, and color vision), 2) presence of strabismus, and 3), measurements of eye size and the dimensions of its components including refractive state. A total of 169 11-year-olds who were born at term were recruited as control subjects and examined under the same conditions. RESULTS: A total of 448 of the original cohort were traced, and 254 consented to a further examination. Compared with the control group, the follow-up cohort differed significantly with reduced visual functions and increased incidence of both myopia and strabismus. Compared with published data, eye size was smaller in the low birth weight cohort. To summarize the ophthalmic data, we defined ophthalmic morbidity as visual acuity below 0.0 log units or the presence of strabismus, myopia, color vision defect, or visual field defect. The rate of ophthalmic morbidity was 50.8% (n = 129/254) in the study cohort compared with 19.5% (n = 33/169) in the control group. The highest rate of ophthalmic morbidity was associated with severe ROP (stages 3/4), although those with no ROP had a less favorable outcome than the control group. CONCLUSION: This study shows that low birth weight children are at increased risk of visual impairments compared with children who are born at full term. Visual impairments are associated with low birth weight per se and severe ROP. Regressed mild ROP is only a risk factor for strabismus. The functional significance of these deficits is largely unknown.

Solving the Medicare equation. Are margins the most effective way to measure a hospital's fiscal health?

Citing soaring hospital profit margins, lawmakers froze Medicare hospital reimbursements for this fiscal year, the first such freeze in history. Critics counter that profit margins don't paint a fair picture of hospitals' financial condition. They complain that recent rosy forecasts by congressional Medicare advisory commissions mask the fact that many hospitals lie on the brink of financial ruin.

Medicare program; establishment of the Medicare Coverage Advisory Committee and request for nominations for members. Notice.

This notice announces the establishment of the Medicare Coverage Advisory Committee that will advise the Secretary of Health and Human Services and the Administrator of the Health Care Financing Administration, as requested by the Secretary, whether medical items and services are reasonable and necessary under title XVIII of the Social Security Act. This notice requests nominations for members for the Committee. This notice also announces the signing by the Secretary on November 24, 1998 of the charter establishing the Committee. This charter ends at close of business on November 23, 2000 unless renewed by the Secretary.

Termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission--GAO. Notice of termination of commissions.

The Balanced Budget Act of 1997 requires the Comptroller General, after the Medicare Payment Advisory Commission has been established, to provide for the termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission. This notice announces the termination of the two commissions.

Understanding the state variation in Medicare home health care. The impact of Medicaid program characteristics, state policy, and provider attributes.

OBJECTIVES: During the past 7 years there has been a significant increase in the use of the Medicare home health benefit. In this article, the authors document trends in the use of the benefit and develop multivariate models to identify the factors that explain state variation in its use. METHODS: To develop quantitative models, the authors collected state information on all variables for each of 3 years: 1991, 1992, and 1993. The authors chose to focus on those variables that had been found to be significant in other research as well as those that we posited would likely influence utilization. The authors tested similar sets of explanatory variables for each year of the analysis. The unit of analysis is the "state" and depending on data availability, the number of states included in the analyses range from between 46 to 49. (Arizona does not have a state Medicaid program.) RESULTS: The authors' analysis shows that interaction exists between state policies and use of the benefit. Utilization is higher in states that face greater fiscal pressure concerning their Medicaid budgets; the lack of state personal care programs increases Medicare use, and, when Medicaid home health expenditures decline, the number of Medicare home health care users increases. There is also an inverse relationship between the number of long-term care and skilled nursing facilities in a state and the use of the benefit. Thus, for some, the benefit serves as a substitute for long-term care needs and, for others, for postacute care needs. CONCLUSIONS: The overlap between the population served and the services provided by state programs and Medicare has given states and providers an opportunity to leverage Federal dollars in lieu of state program dollars. As the Federal government attempts to control expenditure growth, policy-makers must be mindful of how state actions can influence the level and type of Federal expenditure.