Symposium on data in a capitated environment. Introduction.
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Data Collection↗
Biomedical subjects
J Lubitz
Publications and source records attributed to J Lubitz.
Health care use by Medicare's disabled enrollees.
Three million persons under age 65 are entitled to Medicare because of disability. This study examines their Medicare use and mortality. Disabled enrollees had higher health care use and mortality than comparison groups of Medicare's aged enrollees or of the general population under age 65. One type of disabled enrollee, adults disabled as children (over one-half of whom are mentally retarded) show lower use rates than the other types of enrollees--workers and widows. High mortality of the disabled during the 2-year waiting period for Medicare suggests the need to investigate how they pay for care during this period.
Data Collection↗
Outcomes of surgery in the Medicare aged population: rehospitalization after surgery.
Using 1979 and 1980 data, rehospitalization rates following eight common surgical procedures are examined for aged Medicare beneficiaries. Rehospitalization rates within 30 days after discharge from the surgical stay varied considerably among procedures and were higher for older beneficiaries. Patients residing in the Northeast had the lowest rates of rehospitalization, although their rehospitalizations tended to be lengthier than those elsewhere. Rehospitalization rates were also tracked for 9 months following discharge from the surgical stay. For all procedures, rehospitalization rates decreased during the 9 months after discharge, but they remained above the prevailing hospitalization rate for the Medicare aged population for the entire 9 months. Principal diagnoses associated with rehospitalizations within 30 days were often related to the body system on which surgery was initially performed, suggesting that many rehospitalizations are for continuing problems related to the initial condition that necessitated surgery. Rehospitalization rates presented in this article will serve as baseline data for monitoring trends under medicare's prospective payment system for hospitals.
Aged↗
Improving the Medicare HMO payment formula to deal with biased selection.
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Age Factors↗
Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations.
The Tax Equity and Fiscal Responsibility Act of 1982 is expected to make it more attractive for health maintenance organizations (HMO's) to participate in the Medicare program on an at-risk basis. Currently, payments to at-risk HMO's are based on a formula known as the adjusted average per capita cost (AAPCC). This article describes the current formula and discusses a modification, based on prior use of Medicare services, that endeavors to more accurately predict risk. Using statistical simulations, formulas incorporating prior use performed better for some types of biased groups than a formula similar to the one currently employed. Major concerns involve the ability to "game the system." The prior-use model is now being tested in an HMO demonstration. This article also outlines the limitations of a prior-use model and areas for future research.
Forecasting↗
Trends in physician assignment rates for Medicare services, 1968-85.
This article provides an overview of trends in Medicare assignment rates. It covers changes over time in assignment by demographic characteristics and State and analyzes beneficiary liability. Although assignment rates were rising slowly from 1977 to 1983, beneficiary liability was also rising, primarily because of the rise in physician charges and the reduction on allowed charges. Substantial increases in the assignment rate have coincided with the implementation of provisions in the Deficit Reduction Act of 1984 to encourage assignment, and the assignment rate reached on all time high of 69 percent in 1985.
Aged↗
Outcomes of surgery among the Medicare aged: mortality after surgery.
This study examines post-surgical mortality, up to 1 year after surgery, for eight common operations among aged Medicare enrollees. The operations with the highest mortality in the 1.5 months after surgery were femur fracture reduction, hip arthroplasty (other, i.e., not total replacement), and coronary artery bypass. Mortality was still above average for femur fracture reduction, hip arthroplasty (other), and transurethral prostatectomy 1 year after surgery. The highest mortality rates following surgery were for people 85 years of age or over. This raises the following question: Should certain elective surgery be performed at younger ages if it appears that surgery may eventually be needed?
Age Factors↗
Outcomes of surgery among the Medicare aged: surgical volume and mortality.
We examined the relation between surgical volume and mortality, within 60 days of surgery, for eight procedures on aged Medicare beneficiaries. Logistic regression revealed that high surgical volume was significantly associated with lower mortality for resection of the intestine, coronary artery bypass, transurethral resection of the prostate (TURP), and hip arthroplasty (excluding total hip replacement). For cholecystectomy, total hip replacement, inguinal hernia repair, and femur fracture reduction, no relationship was found between surgical volume and postsurgical mortality. The analyses were repeated using inhospital deaths as the dependent variable, and the results indicated a considerably stronger association between volume and mortality.
Aged↗
The use and costs of Medicare services in the last 2 years of life.
This study reports on the use of services by Medicare enrollees who died in 1978. Decedents comprised 5.9 percent of the study group but accounted for 28 percent of Medicare expenditures. The use of services became more intense as death approached. Despite the idea that heroic efforts to prolong life are common, only 6 percent of persons who died had more than $15,000 in Medicare expenses in their last year of life. As shown here, the unique patterns of health care use by decedents and survivors should be fully understood and considered when contemplating changes in the Medicare program.
Aged↗
The rise in the incidence of hospitalizations for the aged, 1967 to 1979.
Since the beginning of the Medicare program in July 1966, the rate of hospitalization for persons age 65 and over has risen steadily. The rate grew more for the aged than for younger age groups. Because of concern about the appropriateness and cost of hospital care, this article examines the increase in hospitalizations for the aged and attempts to identify factors that may explain why the discharge rate rose more for the aged than for younger persons. The article shows that most of the increase in the discharge rate among the aged was associated with an increase in the percentage of persons using the hospital rather than with an increase in rate of multiple hospitalizations. There was also a large increase in the rate of hospital stays of short duration. Examination of changes in diagnostic and surgical case-mix showed that there was a large increase in vascular and cardiac surgeries. Changes in demographic composition and insurance coverage did not help explain the difference in the rate of growth of hospitalizations by age group. The increase in the rate of the aged being cared for in the hospital raises the question of the necessity and quality of the care they receive. Additional studies should focus on the nature and appropriateness of the hospital services rendered to the elderly.
Adolescent↗
Different data systems, different conclusions? Comparing hospital use data for the aged from four data systems.
Four major national data systems collect data on short-stay hospital use by persons age 65 years and over. This paper examines the extent of agreement on the major statistics reported from the four systems and explains, as far as possible, the reasons for discrepancies among the data. The paper also offers some suggestions to the user of hospital care data. The study shows that for national trends the four systems agreed on number of admissions, average length of stay, and days of care. Comparisons across census regions revealed agreement on average length of stay, but showed an unanticipated lack of agreement on admissions. When we examined data on admissions and average length of stay by diagnosis and surgical procedure groups there was agreement among the data systems for most groups, but for certain groups wide differences occurred. The results emphasize the need for data users to understand the nature and limitations of the data they employ. The results also point to a need for data users to consult a number of sources whenever possible.
Aged↗
Analysis of services received under Medicare by specialty of physician.
This paper examines use of physicians' services by Medicare beneficiaries according to the specialty of the physician providing care. The major objectives of this study were to determine which types of physicians are most frequently used, the average charge per service by specialty, the mix of physicians (by specialty) that patients saw during the year, and the amount Medicare reimburses in relation to total physician income. Data were studied for the total Medicare population and by age, sex, race, and geographic area. Claims data for 1975 and 1977 were used from the Part B Bill Summary System. This system collects information from bills from a 5 percent sample of Medicare enrollees. Major findings from this study indicate: (1) Physicians in general practice and internal medicine provided about the same number of services and each far outranked all other types of physicians in numbers of Medicare beneficiaries with reimbursed services. (2) There were marked differences by census region in the use of certain specialists, particularly pathologists, podiatrists, dermatologists, and the specialty group otology, laryngology, rhinology. (3) Average charges per service varied considerably by specialty. Internists' charges averaged 35 percent higher per service than charges by general practitioners. Charges submitted by the surgical specialties far outranked all others and showed the greatest increase during the period under study. (4) Of the total persons with reimbursement physicians' services in 1977, 85 percent saw a primary care physician during the year, while the remaining 15 percent received services from specialists only. (5) Of the total reimbursements made by Medicare, internists received 20 percent, general practitioners received 14 percent, and general surgeons 12 percent. Medicare's payments were estimated to be 21 percent of total gross income for internists, 20 percent for anesthesiologists, and 18 percent for surgical specialties.
Economics, Medical↗
Analysis of variations in hospital use by Medicare patients in PSRO areas, 1974-1977.
A study of the use of short-stay hospitals in PSRO areas by Medicare enrollees aged 65 and over for the period 1974 through 1977 revealed that discharge rates increased, average length of stay (ALOS) decreased, and days-of-care rates remained relatively constant in nearly all of the PSRO areas. The data show large variations in hospital use in PSRO areas within States and HEW regions, and suggest that factors within the area are critical determinants of hospital utilization. This study presents important implications for PSRO program policy for it suggests that factors other than physician and hospital behavior should also be considered when setting objectives for reducing misutilization and improving the quality of health care.
Aged↗
Cost-sharing and prior authorization effects on Medicaid services in California: part I. The beneficiaries' reactions.
In January 1972, California initiated a cost-sharing "experiment" as a means of containing rising costs of the Medicaid program. Beneficiaries who had some personal assets were required to pay a token amount for each doctor visit or prescription. This was expected to deter unnecessary services without affecting really needed care. An interview survey was made of beneficiaries continuously in copayment status throughout the 18 months of the experiment. Most beneficiaries had poor knowledge of the program, and tended to confuse copayment with the concurrent constraint of prior authorization for certain classes of service. The beneficiaries reported that the copayment was almost always collected, and most thought it had not affected their health care, but a significant 17 per cent throught it had reduced the care available to them, and these 17 per cent were for the most part in households with high medical need.
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Cost-sharing and prior authorization effects on Medicaid services in California: Part II: The providers' reactions.
Providers for California's Medical program were interviewed to determine their reaction to the copayment experiment. Private physicians, pharmacists, and nursing homes routinely collected the copayments and though it was not a particular hardship on the patients. Hospital outpatient departments often did not collect. Physicians both in hospitals and in private practice generally did not know which patients were copayers and hence copayment had no effect on their practice. Pharmacists reported some delay and some selectivity on the part of patients in the filling of their prescriptions. All providers felt as much more harassment and interference from the concurrent prior authorization requirements. This effect may have swamped copayment effects.
Attitude of Health Personnel↗
Three decades of health care use by the elderly, 1965-1998.
Over the past three decades health spending and hospital use increased more for the elderly than for persons under age sixty-five. Medicare spending for the oldest old (age eighty-five and older) increased faster than for persons ages sixty-five to seventy-four, but that increase was due entirely to greater postacute care use. Health care trends are consistent with the idea that Medicare has improved the health of the elderly. Greater spending increases for the elderly may reflect legislative developments such as the passage of Medicare and its continued fee-for-service nature and the failure to pass universal coverage, as well as changes in the health care delivery system such as the rapid growth in managed care enrollment among persons under age sixty-five.
Aged↗