Chiropractic and a new taxonomy of primary care activities.

OBJECTIVE: To specify the procedural and cognitive content of primary care and to discuss potential chiropractic primary care roles. DATA COLLECTION: Data were collected through use of two expert panels and a consensus process to create a list of primary care activities. The first panel was an interdisciplinary mix of physicians, mainly allopathic ones; most of the members of the second panel were chiropractors. Each panel rated primary care activities across a number of dimensions, such as importance for good health, frequency in a typical office-based practice, necessity for medical doctor involvement in the activity, competence of the majority of chiropractic physicians, and interest among chiropractors in performing the activity. RESULTS: There was no real difference between the panels in terms of taxonomy scope or importance of the activities for good health. Many of the activities are performed more frequently in a typical medical office than in a typical chiropractic office. With respect to a set of primary care activities that occur daily in medical offices, chiropractors are able to make diagnoses in 92% of the activities and to make therapeutic contributions in more than 50% of the activities. Medical doctor involvement was perceived as required more frequently by the chiropractic panel than by the interdisciplinary panel. Moreover, chiropractors' interests and self-assessments of competence showed some limits with regard to their assumption of total care for some frequently occurring primary care activities. CONCLUSIONS: The most important finding of this activity is the overriding sense of agreement between allopathic and chiropractic physicians in terms of the scope of primary care activities, suggesting that there is opportunity for chiropractors and medical doctors to work together on patient care and organizational strategy. However, the levels of self-assessed competence and interest on the part of chiropractors for many frequently occurring primary care activities reveal some important limits for assumption of total primary care.

Medicare use in the last ninety days of life.

The introduction of Medicare's prospective payment system (PPS) has led to changes in the way hospitals are being used. This article examines concomitant changes in the use of Medicare-covered services during the last 90 days of life, using data on more than 34,000 Medicare beneficiaries who died during the years 1982-1986. We focus on questions pertaining to changes in practice patterns that include location of death, hospital utilization, use of other covered services, and spending. We find that use of hospitals and other health services by Medicare beneficiaries during the last 90 days of life changed markedly over this period, which included the introduction of PPS in late 1983. The percentage of deaths occurring in hospitals decreased sharply from 1982 to 1986, especially in PPS states relative to waivered states; this effect seems primarily due to reductions in length of stay rather than reduced admission rates, which did not change significantly. Use of home care, durable medical equipment (DME), and physicians' office services also increased sharply during the last 90 days of life, but with no consistent evidence that the introduction of PPS was associated with these changes or with the level or mix of Medicare expenditures for these patients. Medicare spending in this period of life rose at the same rate as medical care price inflation, and about 75 percent of reimbursements continued to be hospital payments, despite the utilization changes.

Medicare's prospective payment system: a critical appraisal.

Implementation of the Medicare prospective payment system (PPS) for hospital payment has produced major changes in the hospital industry and in the way hospital services are used by physicians and their patients. The substantial published literature that examines these changes is reviewed in this article. This literature suggests that most of the intended effects of PPS on costs and intensity of care have been realized. But the literature fails to answer fundamental questions about the effectiveness and equity of administered pricing as a policy tool for cost containment. The literature offers some hope that the worst fears about the effects of PPS on quality of care and the health of the hospital industry have not materialized. But because of data lags, the studies done to date seem to tell us more about the effects of the early, more generous period of PPS than about the opportunity costs of reducing hospital cost inflation.

Effects of state prospective reimbursement programs on hospital mortality.

Prospective reimbursement (PR) programs were implemented in a number of states in the 1970s to reduce the rate of inflation in hospital costs. The associated savings have prompted concern about whether hospital administrators have been able to economize in ways that do not compromise patient care. This study examined the effects of PR on hospital mortality in 15 states. A quasi-experimental design was used to compare the 10-year trend in standardized mortality rates in hospitals in these states with those in a national sample of hospitals not receiving PR. Although the introduction of PR was associated with higher mortality on all patient groups studied, there was no indication that the level of cost saving in states under PR was correlated with patterns of mortality rates. We conclude that policymakers must be concerned that PR may be compromising the quality of patient care in hospitals, and that more definitive research is needed to improve understanding of the implied trade-off between cost containment and patient outcomes.

Medicare elective surgery outcomes and state prospective reimbursement programs.

This article examines the relationship between the introduction of State prospective reimbursement (PR) programs and mortality rates for elective surgery. We study 15 such programs using a sample of about 40 percent of U.S. hospitals. We examine mortality data for 1974 to 1983 for these hospitals, selecting a 20-percent sample of all Medicare admissions for eight elective procedures. Indirect standardization (age, sex, procedure) was used to define mortality outcomes, and regression procedures were used to estimate PR effects that controlled for hospital, community, and other regulatory influences. Introduction of PR is found to be occasionally and inconsistently associated with increases in relative mortality.

Impact of the New York Long-Term Home Health Care Program.

The Long-Term Home Health Care Program (LTHHCP), also known as the Nursing Homes Without Walls, is an innovative, comprehensive Medicaid program in New York State that provides nursing home level of care to patients at home. This paper evaluates the performance of the first nine LTHHCP sites over the first 2 years of operation. Across all sites there is clear evidence that the program has been extremely successful in reducing levels of nursing home utilization. In the five upstate sites, considerable cost savings have also been achieved while improving patient survival. In the four New York City sites, patient outcomes have also been favorable, but health care costs for clients have been higher than would have been the case had clients not enrolled in the LTHHCP. Across the entire state, results could have been better if enrollment had been targeted to subsets of the eligible patient groups for whom the LTHHCP is most cost effective.