PubMed Health⌕ Search

Biomedical subjects

Richard A Hirth

Publications and source records attributed to Richard A Hirth.

14 recordsLinked to original sources
PubMed2006

Factor substitution in nursing homes.

This paper studies factor substitution in one important sector: the nursing home industry. Specifically, we measure the extent to which nursing homes substitute materials for labor when labor becomes relatively more expensive. From a policy perspective, factor substitution in this market is important because materials-intensive methods of care are associated with greater risks of morbidity and mortality among nursing home residents. Studying longitudinal data from 1991 to 2000 on nearly every nursing home in the United States, we use the method of instrumental variables (IV) to address measurement error in nursing home wages. The results from the IV models yield evidence of factor substitution: higher nursing home wages are associated with greater use of psychoactive drugs and lower quality.

Cost Control↗
PubMed2006

Understanding the basic case-mix adjustment for the composite rate.

In April 2005, Medicare began adjusting payments to dialysis providers for composite-rate services for a limited set of patient characteristics, including age, body surface area, and low body mass index. We present analyses intended to help the end-stage renal disease community understand the empirical reasons behind the new composite-rate basic case-mix adjustment. The U-shaped relationship between age and composite-rate cost that is reflected in the basic case-mix adjustment has generated significant discussion within the end-stage renal disease community. Whereas greater costs among older patients are consistent with conventional wisdom, greater costs among younger patients are caused in part by more skipped sessions and a greater incidence of certain costly comorbidities. Longer treatment times for patients with a greater body surface area combined with the largely fixed cost structure of dialysis facilities explains much of the greater cost for larger patients. The basic case-mix adjustment reflects an initial and partial adjustment for the cost of providing composite-rate services.

Adult↗
PubMed2006

Cost-effectiveness of hospital pay-for-performance incentives.

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costsfor the payer were dollar 22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between dollar 12,967 and dollar 30,081, a level well under consensus measures of the value of a QALY.

Blue Cross Blue Shield Insurance Plans↗
PubMed2005

Economic impact of case-mix adjusting the dialysis composite rate.

The Medicare program reimburses dialysis providers a flat rate for a bundle of services that comprise the basic dialysis treatment. This payment system is being modified to incorporate case-mix adjustment for age and body size, which have been shown to influence dialysis costs. This study simulated the economic impact of the recently issued Medicare rule on case-mix adjustment by estimating the variation in payments across patients, facilities, and broad classes of facilities. Case-mix adjustment results in considerable patient-level variation in payments (dollar 12.99 SD in case-mix adjusted payments). The variation across dialysis facilities is smaller but still economically significant (dollar 3.77 SD). However, there was little evidence that particular classes of facilities (e.g., ownership, chain membership, size) will be substantially advantaged or disadvantaged by case-mix adjustment. There do seem to be modest changes in the regional distribution of payments.

Adolescent↗
PubMed2003

Competitive spillovers across non-profit and for-profit nursing homes.

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.

Aged↗
PubMed2003

Chronic illness, treatment choice and workforce participation.

Choices with respect to labor force participation and medical treatment are increasingly intertwined. Technological advances present patients with new choices and may facilitate continued employment for the growing number of chronically ill individuals. We examine joint work/treatment decisions of end stage renal disease patients, a group for whom these tradeoffs are particularly salient. Using a simultaneous equations probit model, we find that treatment choice is a significant predictor of employment status. However, the effect size is considerably smaller than in models that do not consider the joint nature of these choices.

Adult↗
PubMed2003

Case management: effects of improved risk and value information.

PURPOSE: The purpose of this study was to determine the impact on resource use of providing case managers with information on the potential for patients to benefit from home care services. DESIGN AND METHODS: Twenty-four case managers working in the Arizona Long Term Care System (ALTCS) were randomized into treatment and control groups. Members of the treatment group were given patient assessments for 25 ALTCS clients, estimates of the patients' risks for various adverse outcomes, and estimates of the aggregate potential benefit for each patient. Members of the control group were given only patient assessments (as is usual practice) for the same sample of 25 clients. Both groups were asked to independently write nonbinding care plans for each patient. The cost of each case manager's care plans was computed by multiplying standard costs per service times the mix and volume of services prescribed for each patient. RESULTS: Treatment group care plan costs were, on average, lower than control group costs and closely tracked variation in estimated patient risks. Comparison group care plan costs were unrelated to risks. IMPLICATIONS: Information about risk and potential benefit can improve targeting of services to long-term-care clients. A prospective study using such an approach is warranted to see if provision of risk and potential benefit information would produce better clinical and economic outcomes.

Aged↗
PubMed2003

Does quality influence consumer choice of nursing homes? Evidence from nursing home to nursing home transfers.

We estimated Cox proportional hazards models using assessment data from the Minimum Data Set to test whether nursing home residents and their proxies respond to quality of care by changing providers. Various indicators of poor quality increased the likelihood of transfer. Residents of for-profit homes or homes with excess capacity also were more likely to transfer. Inability to participate in care decisions and factors indicating frailty limited residents' ability to transfer. The apparent responsiveness to quality is encouraging. Nonetheless, because the absolute transfer rate is low, significant barriers to movement among nursing homes still may exist.

Activities of Daily Living↗
PubMed2003

Is case-mix adjustment necessary for an expanded dialysis bundle?

Congress has required CMS to expand the Medicare outpatient prospective payment system (PPS) for dialysis services to include as many drugs and diagnostic procedures provided to end stage renal disease (ESRD) patients as possible. One important implementation question is whether dialysis facility case mix should be reflected in payment. We use fiscal year (FY) 2000 cost report and patient billing and clinical data to determine the relationship between costs and case mix, as represented by several patient demographic, diagnostic, and clinical characteristics. Results indicate considerable variability in costs and case mix across facilities and a significant and substantial relationship between case mix and facility cost, suggesting case mix payment adjustment may be important.

Adolescent↗
PubMed2002

Using a standardized donor ratio to assess the performance of organ procurement organizations.

OBJECTIVE: To develop a Standardized Donor Ratio (SDR) as an outcome measure for evaluating the effectiveness of organ procurement organizations (OPOs). DATA SOURCES/STUDY SETTING: All deaths by cause in the United States during 1993-1994 as reported in the Vital Mortality Statistics, Multiple Cause of Death files. The OPO-specific data were provided by the United Network for Organ Sharing (UNOS). STUDY DESIGN: Each OPO's expected number of donors was calculated by applying national donation rates to deaths with potential for donation in 24 age, sex, and race cells. The SDR was calculated by dividing the observed number of donors by the expected number. The chi2 tests of the hypothesis that the OPO's performance differed from the national norm of 1.0 were performed. The SDR was compared to the existing performance standard based on the unadjusted number of donors per million live population in the OPO's service area. An ordinary least squares (OLS) regression assessed predictors of the SDR. PRINCIPAL FINDINGS: The SDRs ranged from 0.41 to 1.99. Twenty-nine of 64 OPOs had SDRs significantly different than 1.0. The SDRs were positively associated with the percent of white living population and the number of organ types transplanted per transplant center served by the OPO. CONCLUSIONS: The SDRs can be used by Centers for Medicare and Medicaid Services (CMS), UNOS, and OPOs to target quality improvement initiatives, present more accurate comparisons of OPO performance, and develop public policy on the evaluation of the effectiveness of organ procurement efforts.

Adolescent↗
PubMedDate not supplied

Increased spending on health care: how much can the United States afford?

Perceptions of whether health care cost growth is affordable contribute greatly to pressures for health system reform. In this paper we develop a framework for thinking about affordability, concluding that a one-percentage-point gap between real per capita growth in health care costs and growth in GDP would be affordable through 2075. A two-percentage-point gap would only be affordable through 2039. In either case, the share of income growth devoted to health care would exceed historical norms. The value of care, which determines willingness to pay, and distributional issues are more important than our ability as a society to pay for care.

Actuarial Analysis↗
PubMedDate not supplied

The effect of Medicare's prospective payment system on discharge outcomes of skilled nursing facility residents.

In July 1998, the Centers for Medicare and Medicaid Services (CMS) changed the payment method for Medicare (Part A) skilled nursing facility (SNF) care from a cost-based system to a prospective payment system (PPS). Unlike the previous cost-based payment system, PPS restricts skilled nursing facility payment to pre-determined levels. CMS also reduced the total payments to SNFs coincident with PPS implementation. These changes might reduce quality of care at skilled nursing facilities and could be reflected in resident discharge patterns. The present study examines the effect of the 1998 policy change on resident discharge outcomes. The results indicate that PPS reduced the relative risk of discharge to home and to death for Medicare residents (compared to non-Medicare residents) and had no significant effect on hospitalizations or transfers.

Aged↗
PubMedDate not supplied

The effects of preferred provider organizations on costs and utilization of hysterectomy.

In this study, the costs and service utilization of preferred provider organizations (PPOs) were compared against traditional indemnity plans with similar benefits and utilization review for hysterectomy, a potentially overused procedure. PPOs were associated with significant cost savings, achieved primarily through lower utilization rates.

Adult↗