Biomedical subjects
Publications and source records attributed to J Cromwell.
Varying perceptions of gender, sex, and sexuality are investigated, using several examples, from the Pokot of East Africa to the Tewa Indians in New Mexico. The role that labels play in the acquisition of gender identity is also explored; and the influence of Cartesian dualism is challenged, suggesting a need to expand Euro-American conceptions of gender.
The delivery of anesthesia services is at a crossroads in the United States. In 1967, there were two certified registered nurse anesthetists (CRNAs) for every anesthesiologist providing anesthetics, and the numbers are nearly equal today. A CRNA manpower forecasting model is developed in this article that shows CRNA supply and requirements from 1990 through 2010. Two estimates of CRNA shortage are presented, one based on the current trend of anesthesiologists replacing CRNAs and another assuming that CRNAs are involved in every anesthetic under anesthesiologist supervision. The results imply that more than a twofold increase in CRNA school enrollments is needed just to fill conservative baseline needs given the predicted growth in operations in all settings. Limiting anesthesiologists to a supervisory role, at the other extreme, would require a doubling of CRNAs by 2010 and an even greater expansion of CRNA schools. However, it is estimated that reversing CRNA manpower trends could save society between $750 million and $1.2 billion annually.
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Nurse anesthesia manpower needs over a 20-year period from 1990 through 2010 are examined using data from a study conducted by Health Economics Research, Inc., which was submitted to Congress in February 1990. Two scenarios were considered: one representing no change in the capacity of the educational system and the other an annual increase. Under either scenario, the U.S. faces a significant shortage of CRNAs, now and in the future. The study points to a $1.2 billion savings to society through the increased use of CRNAs in anesthesia care.
This study provides empiric confirmation of the widely held belief that coronary artery bypass graft (CABG) surgery has become quicker over time as clinical and organizational improvements diffuse across hospitals. Based on a two-stage cluster sample of 74 hospitals performing CABG surgery in 1984, data on skin-to-skin procedure and pump times were analyzed for 2,784 Medicare-eligible cases over the 1972-84 period. Using multivariate regression analysis to adjust for patient characteristics and number of grafts, we found that CABG skin-to-skin times fell an average of 36.5% during the first 12 years of hospital experience while cardiopulmonary pump times fell 28.2%. Rates of decline averaged 4.5-5.4% annually initially, but tapered off to 1.5% by the twelfth year of experience. Extrapolating over a 20-year period, gains in skin-to-skin times are projected to reach 42%, resulting in nearly a halving of surgical times. Our findings have implications both for physician reimbursement and patient outcomes. Medicare CABG prevailing fees do not reflect these gains in efficiency and could be reduced substantially. Alternatively, efficient, high-volume hospitals could be identified for inclusion in a Medicare "CABG PPO" so that society might share in the productivity gains. Finally, recent research showing better outcomes in high-volume institutions may be partially explained by their shorter procedure times, which should reduce operative complications.
The rapid growth in Medicare Part B spending on physicians has sparked a renewed debate on ways of increasing physician productivity. This study concentrates on anesthesiologists, presenting original survey data on the variation in productivity defined in terms of patients, anesthesia hours, base and time units, and revenues. Supervising nurse anesthetists are estimated to raise anesthesiologist productivity by at least 20%, allowing for downtime and scheduling problems. Greater delegation could save society approximately $500 million annually in anesthesiologist costs, even allowing for an increase in nurse anesthetists. Yet, recent manpower trends show a falling nurse-to-anesthesiologist ratio. The failure to achieve substantial gains is ascribed to a flaw in third-party reimbursement that discourages both hospitals and physicians from substituting nurse for anesthesiologist time.
Nurse anesthetists (CRNAs) are a lower cost substitute for anesthesiologists in the delivery of anesthesia services. This article addresses the question of when anesthesiologists delegate in a team approach as opposed to using a solo arrangement. Logistic regression analysis was done using data from the 1986 Anesthesia Practice Survey and revealed that the team approach is more likely in areas with a relatively large supply of CRNAs; in hospitals with large surgical volumes, teaching facilities, and public hospitals; during emergency procedures, more lengthy procedures, and less complex surgeries; and among patients with poorer preoperative physical status. However, as the supply of anesthesiologists increases, the probability of CRNA use declines and in areas outside New England the "solo anesthesiologist" arrangement is significantly more common. Medicare and other third-party payers should eliminate regional variations in provider mix that are due to locational preferences and provider attitudes. Delegation to CRNAs can be encouraged by reducing what anesthesiologists are paid for practicing alone.
Recently, budget-conscious policymakers have shifted their attention to the physician services market and have begun to consider a wide variety of price regulatory schemes for moderating expenditures in this market. In a recent article in this journal, Feldman and Sloan warned that price controls on physician services may cause undesirable declines in service quality, independent of their budgetary ramifications. Our aim in this article is to reconsider the effects of price controls in the broader context of insurance coverage and moral hazard. Our ultimate goal is to assess the benefits of price controls independent of specific assumptions about the controversial issues of demand inducement and income targeting. Using a simple extension of the Feldman/Sloan model, we find that price controls can be and almost certainly are welfare-improving as long as consumers are sufficiently well insured, regardless of where one stands on the inducement issue. The salutary effects of price controls, on the other hand, can be compromised by income-targeting behavior on the part of physicians. We also introduce evidence from Medicare's recent fee freeze to evaluate the possibility of income-targeting behavior empirically. While formal studies of income targeting suggest that its magnitude is small in cross-section, we warn that its effects may be larger over time; this is what our descriptive evidence suggests. We conclude that more dramatic short-term progress on physician fee inflation will require stronger measures, such as putting physicians at risk for consumer expenditures.
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When Congress in 1983 legislated a new Prospective Payment System (PPS) for Medicare hospital payment, the payment algorithm was founded on a simplifying assumption of a constant 80-20 percentage share of labor and nonlabor costs across all diagnosis-related groups (DRGs). Using Medicare claims data and hospital cost reports, this study examines the accuracy of this assumption. While a few DRGs are found to vary significantly from the norm, a systematic cancelling out of high and low labor-intensive DRGs results in no material PPS payment bias at the hospital level. Indeed, rural hospitals, if anything, benefit by the assumption. A very small number of outlier DRGs and hospitals are troublesome, nonetheless, implying fine-tuning of the algorithm.
Physician fees have come under increasing scrutiny as policymakers attempt to constrain Medicare outlays. Our study tests the hypothesis that relative fees can be explained in terms of the physician effort involved. Our regression results show that the majority of the variation in Medicare allowed charges can be justified in terms of the physician time involved and the complexity of the procedure. Nevertheless, some surgical procedures were identified as being "overpaid" relative to their reported time and complexity, while other services appeared "underpaid," especially visits. Our methodology provides a tool for identifying "mispriced" procedures, should Congress continue its current policy of making adjustments to individual fees.
This paper takes advantage of a unique set of annual MONITREND data from the American Hospital Association (AHA) to study the effects of Medicare's Prospective Payment System (PPS) and other public/private programs on hospital productivity and intensity between 1980 and 1987. The results on over 30 cost centers show major improvements in inpatient productivity per discharge in the first two years of PPS--improvements that are largely attributable to shifts of care to the outpatient department. Inpatient intensity, which was growing 4.5% annually between 1980 and 1982, turned negative from 1983-85 due to this shifting locus of care. Productivity per intermediate service also improved but at a slower rate because of the large declines in inpatient volumes. Productivity improvements were greater in urban hospitals, resulting in slower cost inflation and a better financial position compared with rural hospitals.
This article evaluates the claim that rural referral centers (RRCs), identified by HCFA criteria for special treatment under Medicare's prospective payment system, have average costs similar to urban hospitals. Multivariate analysis led us to conclude that RRC Medicare costs were 13 percent higher than those of other rural hospitals in 1984, holding constant Medicare case mix, teaching activity, and relative wages. However, RRCs were 9 percent ($200) less costly per case than urban hospitals. Outliers explained most of the cost difference between RRCs and urban hospitals, while transfers were more important in explaining differences between RRCs and other rural hospitals. Given that bed size alone explained all of the RRC-other rural cost difference, paying RRCs the urban rate results in an indirect way of paying them based on bed size. It also gives them an average excess of payment over Medicare cost well above the national rural and urban average.
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Although there is a general feeling that, into the early 1980s, overall improvement was occurring in the content and quality of physicians' services, no time-series documentation to date has appeared to support this assumption. This article provides empirical evidence that physicians' office visits were in fact changing over time, though not in ways that one might expect. Rather than involving more diagnostic services, such as laboratory tests and x-rays, the typical office visit had come to include more therapeutic services, especially counseling. This is consistent with the observed increase in time spent with patients: between 1974 and 1981, the average office visit increased in length by nearly one full minute. Multivariate analysis indicates that the typical office visit was changing largely because physicians themselves were changing. Not only were physicians becoming increasingly specialized, but they were also more likely to be female, in group practice, and board-certified.
This paper explores the access and equity implications to the poor and taxpayers of further defederalizing Medicaid program administration. New data on enrollees and tax incidence indicates little horizontal, let alone vertical, equity in the system. Styles of cost control are also examined, showing a systematic bias towards providers and taxpayers at the expense of the poor in penurious states.
More than a quarter of the rapid growth in physician expenditures since the advent of the Medicare program can be ascribed to greater service intensity, generally through unpackaging of physician services, procedure inflation, and the involvement of multiple physicians. One way to achieve effective cost control is to restrain prices and the number of services simultaneously through redefining the payment unit from a narrow procedure to a comprehensive package of services. In this paper, we explore five means of packaging physician services: collapsed procedure, office visit, special procedure, ambulatory condition, and inpatient condition packages. While three packages hold promise for reining in the costs of physician services in the Medicare program, two raise important policy considerations that would have to be addressed before they could be given further consideration.