Hospital payment effects on acute inpatient care for mental disorders.

We examined the extent to which inpatient care for patients with mental disorders in general, acute care hospitals responds differently to two types of prospective hospital payment. In Maryland, hospitals have been regulated since 1976 under two forms of payment based on per-service and per-case definitions of hospital output. The study utilizes a 20% sample of 58,000 mental-disorder discharges from 21 per-case- and 24 per-service-reimbursed hospitals in Maryland between fiscal years 1977 and 1980. The effects of payment method on length of stay are examined through the application of multivariate regression models. The empirical results are generally consistent with the notion that the per-case payment method provides some incentives for hospitals to reduce the length of stay. The regulatory effects, however, vary with patient characteristics, particularly by diagnosis.

Use of general medical care services by persons with mental disorders.

Data are presented on the medical diagnoses and the type of general medical services used by persons with mental disorder diagnoses. This study is based on the 1975 experience of registrants in four medical programs contained in three organizational settings. The data on services were retrieved from each program's automated date system. The percent of patients seen in general medical departments receiving a mental disorder diagnosis ranged from 4.8% to 13.6% among the four programs. Patients with mental disorder diagnoses visit general medical departments from 11/2 to two times as frequently as patients without such diagnoses. Persons with a diagnosed mental disorder are likely to receive care for conditions in more International Classification of Diseases categories than other patients, and are more likely to receive a diagnosis for ill-defined conditions, signs, and symptoms.

Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids.

BACKGROUND: Overuse of inhaled beta-agonists and underuse of inhaled corticosteroids by patients with asthma may have adverse consequences. This study was performed to identify factors associated with misuse of these types of asthma medication. METHODS: We examined baseline data from a longitudinal survey of adult patients with asthma. The setting was a consortium of 15 national managed care organizations serving 11 large employers. Baseline surveys were completed by 6612 health plan enrollees at least 18 years old who had had at least 2 visits with a diagnostic code for asthma in the preceding 2 years. The main outcome measures were the overuse of inhaled beta-agonists and the underuse of inhaled corticosteroids. Independent variables were patient and process of care factors. RESULTS: Among patients with moderate or severe asthma, 16% of users of inhaled beta-agonists reported overuse (>8 puffs per day on days of use), and 64% of users of inhaled corticosteroids reported underuse (use on < or =4 days/wk or < or =4 puffs per day). Overuse of inhaled beta-agonists was most strongly associated with concomitant treatment with inhaled corticosteroids or anticholinergic agents, increased asthma symptom severity, problems in obtaining asthma medication, and male sex. Underuse of inhaled corticosteroids was associated with nonwhite race, younger age (18 to 34 years), lower use of inhaled beta-agonist, lower symptom severity, and not possessing a peak flow meter. Rates of misuse of medication also varied by speciality of the patient's provider (generalist, allergist, or pulmonologist). CONCLUSIONS: Overuse of inhaled beta-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate. This study demonstrated an important opportunity to improve medication use among patients with asthma.

Variations in utilization of health services by children.

In this longitudinal study in two prepaid group practices, many more children stayed at the same level of use of services over a six- to ten-year period than would be expected if use of services had distributed randomly. Overall, about 13% remained consistently in the highest third of the distribution of use, and another 13% remained consistently in the middle or lowest third. If use of services had distributed randomly, 4% and 7%, respectively, would have been in these groups. Conversely, many fewer children (25%) showed fluctuating patterns of use over time than would be expected by chance alone (37%). Although the reasons for this phenomenon are unknown (and may be multiple), the findings have implications both for clinical care and for development of policy regarding the organization and financing of health services for children.

Do ophthalmologists, anesthesiologists, and internists agree about preoperative testing in healthy patients undergoing cataract surgery?

To assess variation in reported use of preoperative medical tests in patients undergoing cataract surgery and to identify factors that influence test use by different physician groups we performed a national survey of ophthalmologists, anesthesiologists, and internists. Participants included randomly selected members of American professional societies who provided care to one or more patients undergoing cataract surgery in 1991. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists, 109 (76%) of 143 anesthesiologists, and 54 (44%) of 122 internists. Fifty percent of ophthalmologists, 40% of internists, and 33% of anesthesiologists frequently or always obtained a chest x-ray film, while 20% of ophthalmologists, 27% of internists, and 37% of anesthesiologists never obtained a chest x-ray film for patients being considered for cataract surgery who had no history of major medical problems (P < .01 for differences between ophthalmologists and the other groups). Similarly, 70% to 90% of ophthalmologists, 73% to 79% of internists, and 41% to 79% of anesthesiologists frequently or always obtained a complete blood cell count, electrolyte panel, and electrocardiogram, while 4% to 11% of ophthalmologists, 13% to 17% of internists, and 9% to 28% of anesthesiologists never obtained these tests for such patients. Many respondents (32% to 80%) believed tests were unnecessary but cited multiple reasons for obtaining tests (eg, medicolegal concerns and institutional requirements). Many physicians in each group viewed preoperative evaluations as screening opportunities or believed that one of the other two types of physicians "required" tests. We conclude that marked variation exists within and across physician specialties in the use and rationale for use of medical tests in patients undergoing cataract surgery.

How will outcomes management work?

A consortium of employers and managed health care organizations has come together to test the feasibility and usefulness of an outcomes management system, a new strategy for providing information on what types of medical care are effective, for whom, and under what circumstances. Systematic measurement of health outcomes can provide the information that patients, providers, and insurers/employers need to make informed choices among alternative treatments and services. A pilot project in thirteen sites found that outcomes management is feasible for evaluating ongoing care for chronic conditions but is difficult to apply for short-term diagnostic or treatment episodes. Further, successful implementation requires a commitment of substantial organizational resources.

Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations.

Beginning in 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientific evidence. These Treatment Recommendations, presented here in final form for the first time, are based on exhaustive reviews of the treatment outcomes literature (previously published in Schizophrenia Bulletin, Vol. 21, No. 4, 1995) and focus on those treatments for which there is substantial evidence of efficacy. The recommendations address antipsychotic agents, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, and assertive community treatment/intensive case management. Support for each recommendation is referenced to the previous PORT literature reviews, and the recommendations are rated according to the level of supporting evidence. The PORT Treatment Recommendations provide a basis for moving toward "evidence-based" practice for schizophrenia and identify both the strengths and limitations in our current knowledge base.

Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey.

To examine the conformance of current patterns of usual care for persons with schizophrenia to the Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations, the PORT surveyed a stratified random sample of 719 persons diagnosed with schizophrenia in two States. The types of treatment settings surveyed included acute inpatient programs and continuing outpatient programs in urban and rural locales. Using data from medical record reviews and patient interviews, the PORT assessed the conformance of current care with 12 of the Treatment Recommendations. The rates at which patients' treatment conformed to the recommendations were modest at best, generally below 50 percent. Conformance rates were higher for pharmacological than for psychosocial treatments and in rural areas than in urban ones. Rates of Treatment Recommendation conformance for minority patients were lower than those for Caucasians, and patterns of care varied between the two States. The findings indicate that current usual treatment practices likely fall substantially short of what would be recommended based on the best evidence on treatment efficacy. This disparity underscores the need for greater efforts to ensure that treatment research results are translated into practice.

Treatment outcomes in schizophrenia: implications for practice, policy, and research.

Outcomes research on treatments for schizophrenia has identified a number of efficacious interventions. The degree to which such scientific knowledge influences the care delivered in everyday practice depends on a large number of patient, practitioner, service system, and other social factors. The current atmosphere for change in the health care delivery system poses both risks and opportunities to improve care for persons with this disorder. Scientific knowledge about treatment outcomes must inform this rapid evolution of practice, policy, and research to ensure that effective treatments are preserved and available for all who need them and that new treatments continue to be developed, evaluated, and disseminated.

Economic rents derived from hospital privileges in the market for podiatric services.

This study examines the relative impacts of human capital and market conditions on the economic rents associated with hospital privileges in the market for footcare. An empirical model of hospital privileges for podiatrists is formulated based on the Pauly-Redisch model of hospital behavior. The privilege model is then incorporated into a model of podiatrists' earnings via a selection adjustment as proposed by Heckman and Lee. The results indicate the persistance of economic rents even after controlling for unobserved 'quality' factors.

The Johns Hopkins ambulatory-care coding scheme.

A classification and coding system for ambulatory-care problems has been developed at the Johns Hopkins Medical Institutions and three affiliated institutions. The provider's statement of the patient's problem, as recorded on an encounter from, is kept in a computer file. Codes from the classification scheme, based on those used in four existing schemes, are automatically assigned to diagnoses, symptoms, well-care services, and treatment procedures categorized by physiological system and subsystem. About 85 percent of recorded problems are machine-codable; the remainder are alphabetized for efficient manual coding. The coding system is integrated with an overall information system that allows linkage of coded problem data to diverse data on patient and provider characteristics. Examples are given of the uses and limitations of the linked data for care evaluation, management, and clinical research.

Trauma case mix and hospital payment: the potential for refining DRGs.

Uniform hospital discharge abstract data from Maryland were used to examine the homogeneity of trauma-related DRGs with respect to a well-established measure of injury severity, the Injury Severity Score (ISS). Thirty DRGs were identified as including trauma cases with a wide range of severity; for each of these DRGs, ISS explains a significant amount of variation in length of stay. By applying statistical techniques similar to those used to create the original DRG groupings, these 30 DRGs were subdivided by severity and age categories to create a new set of severity-modified DRGs. The potential effects of using DRGs and modified DRGs to pay for inpatient care within the Maryland state regionalized system of trauma care were examined. Payments based on regional averages per DRG and per modified DRG were compared to actual hospital charges regulated by the state's Health Services Cost Review Commission. Using average charges per DRG as a basis of payment, approximately !1.4 million (11 percent of total hospital charges) would be shifted from trauma centers to nontrauma centers. This shift represents an 18 percent loss in revenues to trauma centers and a 30 percent gain in revenues to nontrauma centers. Using a payment system based on severity-modified DRGs, trauma centers would still experience a net loss in revenues and the nontrauma centers a net gain, but the total amount of the shift would be reduced from $11.4 million to $9.8 million. The results argue for the need to explore alternative payment systems not strictly based on current DRGs. Because of DRGs do not adequately reflect severity differences, using them to pay hospitals will create financial incentives that discourage regionalization of trauma care.

Ambulatory care practice variation within a Medicaid program.

STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.

Impact of hospital discharge planning on meeting patient needs after returning home.

This study examines the contribution of hospital discharge planning in meeting the needs of patients for care after their return home. A random sample of 919 admissions (age 60 and over) to five hospitals was studied to obtain information on characteristics of discharge planning during the patients' hospital stay. Specifically, information was obtained on the involvement of a designated professional for managing and coordinating the discharge plan, and the extent to which the planning was interdisciplinary. Patient interviews conducted two weeks after discharge provided information on needs for care related to: (1) treatment, (2) activity limitations, and (3) other self-sufficiency limitations. Patients were asked about their need for care in these three areas and about whether or not these needs were being met. Overall, 97 percent reported one or more needs for care and 33 percent reported that at least one of these needs was not being met. Findings show that the involvement of a discharge planning case manager is related to a significant reduction in unmet treatment needs, but not to reductions in activity limitation, other self-sufficiency needs, or overall needs. No significant effects of interdisciplinary planning were identified. These findings suggest that treatment-related benefits result when a case manager has specific responsibility for the discharge planning of elderly patients returning home after hospitalization. These results provide insights into what is being achieved through current discharge planning practices. The meeting of specific patient needs through enhanced discharge planning may save future costs by reducing the rates of complications and hospital readmissions in an era of prospective payment, thus potentially offsetting the increased costs involved in planning and coordinating postdischarge care for older adults.

Utilization and case-mix impacts of per case payment in Maryland.

Maryland has simultaneously operated per case and per service hospital payment systems since 1976 with varying levels of stringency in setting per case rates. Regression analyses of this experience are used to compare the impacts of these systems on admissions, length of stay, and case-mix costliness from July 1, 1976 to June 30, 1981. Our results indicate a positive effect on admissions and negative effects on case mix and length of stay for the per case payment approach relative to the per service approach. More stringent levels of per case payment are associated with stronger utilization responses.

Principles for assessment of patient outcomes in mental health care.

With the dramatic changes that are occurring in mental health and substance abuse treatment systems, it is imperative that the field keep its focus on the patient and the patient's outcomes of care. Outcomes management systems that measure the processes of care, the patient's characteristics, and the patient's outcomes of care can be helpful in maintaining this focus. To facilitate the development of these systems, the Outcomes Roundtable, a group of mental health consumer, professional, service, and policy-making organizations, has articulated a set of 12 broadly applicable principles of outcomes assessment. The principles call for outcomes assessments that are appropriate to the question being answered, that use tools with demonstrated validity and reliability and sensitivity to clinically important changes over time, and that always include the consumer perspective. In addition, the principles recommend outcomes assessments that create minimal burden for respondents and are adaptable to different health care systems, that include general health status as well as mental health status, and that include consumers' evaluation of treatment and outcomes. Outcomes assessment tools should quantify the type and extent of treatment, should include generic and disorder-specific information, and should measure areas of personal functioning affected by the disorder. Outcomes should be reassessed at clinically meaningful points in time. Outcomes assessment should use appropriate scientific design and representative samples and should examine outcomes of consumers who prematurely leave treatment as well as those who continue in treatment.

Building research capacity into a national physician database.

The range of physician financial arrangements with managed care and insurers, as well as practice arrangements, is becoming increasingly complex. Little is known systematically about these changes, yet there is growing evidence that financial arrangements, utilization management, and other practice characteristics make a substantial difference in treatment patterns, patient mix, and costs of care. Current data systems and surveys frequently do not capture the new information needed to track these changes. New elements of information should be included in national surveys and in a national physician database. A list of recommended data items for a national data base is provided as a starting point for identifying a minimal data set to be included in national statistical systems.

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Hospital cost and efficiency under per service and per case payment in Maryland: a tale of the carrot and the stick.

The simultaneous operation of per case and per service payment systems in Maryland, and the varying levels of stringency used in setting per case rates, allows a comparison of the effects of differing incentive structures on hospital costs. This paper presents such a comparison with 1977-1981 data. Regressions performed on cost-per-case and total cost data indicate that costs were lower only when per case payment limits were very stringent. Positive net revenue incentives appeared to be insufficient to induce a reduction in length of stay or ancillary services use. These changes in medical practice patterns thus appear more likely under the threat of financial losses--that is, under the threat of the stick rather than the inducement of the carrot.

Improving quality and accessibility in our health care system: cost effective controls in a reformed system.

We need to examine the elements of health reform and to debate them based on what type of health care system we want in the future. If we continue down the current course, the numbers of uninsured will grow; benefit coverage will be reduced; increasing numbers of small employers will not be able to afford to buy coverage; and, we will rely on cost shifting to pay for emergency and critical care for those who cannot pay. The alternative is to strive to remove unnecessary costs from our current system, to assure universal coverage, and to emphasize preventive and early ambulatory care over emergency and delayed care. This will cause some disruptions and will put some constraints on the independence of providers and patients. But this is already happening, and frequently without the input of either provider or patient. The insurer and employer are making many of these decisions. Health care reform needs to support patients and providers as the key decision-makers; I believe the President's plan will move us in this direction. I think now is the time to make health reform work for us. I do not see any catastrophic changes that will erode quality of care or the livelihood of health professionals. However, I do see an increasingly bleak future if we delay longer and avoid addressing the fundamental issues of access to high quality care for all Americans at an affordable cost.