Biomedical subjects
Publications and source records attributed to S T Fleming.
This article addresses the issue of breakeven analysis as applied to managed care under capitation. The traditional two-dimensional breakeven analysis is expanded into three dimensions: cost, enrollment, and utilization. This issue is examined and then visualized through the use of three-dimensional graphics.
In this article, the methodology used by the Health Care Financing Administration in the 1992 release of 1990 mortality statistics is described, and the performance of one outlier hospital is evaluated as a case study. The study hospital is compared to all other hospitals, and to a smaller cohort of 200-to-299-bed minor teaching hospitals, in terms of predicted and observed mortality rates and mortality model determinants. Proportionately more patients treated in the study hospital were women and had cerebrovascular degeneration or chronic renal disease; fewer patients had cardiovascular disease. Substantially more patients from this hospital were transfers from a skilled nursing facility. Fewer patients were admitted through the emergency department. Although patients tended to be more seriously ill overall compared with other hospitals in the country, observed mortality rates were still higher than predicted. Possible explanations for the discrepancy were coding inconsistencies, inability to control adequately for the severity of illness of transfers from skilled nursing facilities, or quality of care problems.
This study explored the prevalence of comorbid conditions in hospitalized patients with multiple sclerosis (MS) who were 65 years of age or older. Using 1989 data from the Quality of Care Medicare Provider Analysis and Review (MEDPAR) file, hospitalized MS patients were compared with respect to discharge diagnoses to an age- and sex-matched group of hospitalized patients without MS. As expected, the following discharge diagnoses were more common (P < 0.05) for MS patients: urinary tract infection, pneumonia, septicemia and cellulitus. In contrast, MS patients were less likely (P < 0.05) to have discharge diagnoses of acute myocardial infarction, heart failure, hypertension, angina pectoris, cerebrovascular disease, diabetes mellitus and chronic obstructive pulmonary disease. Possible explanations include under-reporting of certain comorbid conditions on discharge records of MS patients, a protective effect of MS or its treatment, reduced prevalence of risk factors, disproportionate mortality in younger MS patients with comorbidity and the benefits of medical surveillance.
The article explores the relationship between the cost and the quality of hospital care by elaborating a conceptual model of hospital performance. The model relates the financial health status of an organization (financial integrity) to the quality of care provided by that organization (clinical integrity) within an environment that is characterized by various forms of risk. The model suggests that both concepts determine the corporate destiny (success, bankruptcy, or merger) of the organization. If this model proves valid empirically, the results could be used as an early warning system to identify hospitals that might experience financial or clinical distress.
Psychiatric DRGs are identified in terms of their relative profitability within each hospital of a 386 hospital cohort. It is then determined whether hospitals admitted more of the more profitable and fewer of the less profitable patients over the period 1983-1987 (skimming). Also determined is whether hospitals discharged more of the less profitable to other short term hospitals over the same period of time (dumping). The findings generally indicate that this did not happen.
In many ways the spread of total quality management (TQM) across this country can be compared to a religious conversion. Both cases are characterized by a philosophical shift with far-reaching changes in responsibilities and incentives for the people involved. This article bridges the disciplines of theology and health services management by elaborating a metaphor in which TQM is compared to various aspects of the Judeo-Christian faiths, such as the role of laws and standards; the importance of miracles, prophets, and evangelists; and the practical applications of living out the faith.
This paper describes a pilot study involving 4347 patient abstracts collected by anesthesia providers during the first quarter of 1991 under the auspices of the American Association of Nurse Anesthetists. Descriptive statistics are presented on surgical site, type of provider and utilization of anesthetic agents as well as the prevalence of 87 preexisting conditions and the incidence of 103 adverse events.
This paper describes the development of risk-adjusted mortality indices (RAMI) using 1985 MEDPAR data from 657 hospitals. The RAMI methodology is adopted from the Commission on Professional and Hospital Activities, however, both inhospital and post-discharge deaths are counted within time windows that vary by clinical condition. Five different RAMI measures (expected deaths/observed deaths) are developed, compared, and aggregated into various hospital characteristic strata. These measures vary by which discharge is held responsible for deaths within a time window, and whether or not inhospital deaths that occur beyond the time window are included. The RAMIs using varying time windows are compared with the RAMIs based upon inhospital deaths only. The inhospital RAMI was higher for the nonteaching hospitals (.95) as compared with the major and minor teaching institutions (.91 and .89). The RAMIs using the varying time windows, on the other hand, tend to be higher for the teaching institutions (e.g., 1.07 for major teaching hospitals; 0.99 for nonteaching hospitals).
This study focuses on the relationship between the quality and the cost of hospital care. I report the findings of variable cost regressions that include outcome indicators of hospital quality: risk-adjusted mortality and readmission indices. Hospital level data are aggregated from a modified 1985 Medicare Provider Analysis File (MEDPAR) and the Commission of Professional and Hospital Activities. Results show several quality measures to be statistically significant determinants of cost. With each measure, the cost-quality relationship is nonlinear but not monotonically increasing throughout the entire range of quality.
Five separate hospital products are identified based on the concept of the amount of disease remission achieved by the hospital. The parameters of this concept are illness level on admission and discharge location. In a cohort of 646 nonfederal, short-term hospitals over the period 1980-1984, changes in the hospital product are examined separately in the 50 diagnosis-related groups (DRGs) with the greatest volume of Medicare discharges. Productivity changes, as defined by the number of certain inputs, are also examined. In both sets of analyses, patient severity level is controlled for by indexing to the base year (1980) case mix. The purpose of this study was to examine whether the dramatic product and productivity changes following implementation of the prospective payment system, as found in our earlier work, were across-the-board changes or the result of selective changes, specific to certain DRGs or products. The results suggest that the changes were an across-the-board phenomenon. Policy implications are discussed.
The present Medicare Diagnosis Related Group (DRG) classification system contains 95 DRG pairs, where one DRG of the pair contains patients within a distinct diagnostic category who are under 70 years of age with no comorbidities or complications (CCs). The other DRG of the pair contains patients in the same diagnostic category who are over 69 or who have CCs. This study examines whether it is appropriate for reimbursement purposes to group those patients who are 70 years of age or older but have no CCs with patients who have CCs. Our findings show that age alone, in the absence of CCs, increases length of stay and cost of care only slightly. In fact, using only CCs as a classification variable reduces the within-group variance more than the present classification based on both age and CCs. Therefore, it is inappropriate to group Medicare patients who are older than 70 years of age without CCs with Medicare patients who have CCs.
The Commission on Professional and Hospital Activities (CPHA) developed the Risk-Adjusted Mortality Index (RAMI), a method for comparing hospital death rates using existing abstract or billing data. The method is comprehensive insofar as it includes all payers and all types of cases except neonates. RAMI was designed to differentiate among admissions on the basis of the patient characteristics that increase or reduce the risk of dying in the hospital. Using a large national data base, risk factors were determined empirically within each of 310 clusters based on diagnosis-related groups (DRGs). The model was very effective at predicting risk-adjusted outcomes, with a correlation of 0.98 between actual and predicted deaths in a sample of 300 hospitals. RAMI appears to be a powerful tool for using existing data to monitor changes over time in hospital death rates.
The results suggest that Prospective Payment System (PPS) prompted a reduction in the proportion of Medicare patients that were discharged, for whom the hospital considered the episode of care to be completed. The results also show a reduction in the proportion of patients discharged dead. When controlling for patient type, the results support the findings, but the magnitude of the change that might be attributed to PPS is somewhat smaller. Proportional changes in the input measures for all patients were next considered. The results indicate that fewer diagnostic tests, fewer laboratory tests, and fewer x-rays were used in 1984. Laboratory tests showed the most dramatic decrease. LOS decreased, but the drug input remained fairly constant. A productivity index that reflects the change in the input measure while controlling for patient type was developed. The results provide strong evidence of a productivity increase in all products for Medicare patients. The drug input did not contribute to the productivity increase. The 50 most frequent DRGs for Medicare patients were examined separately for productivity changes by product. The results further support the findings of an increase in productivity.
In this update of a study of high-cost illness, we analyzed data on 1,455,766 discharges from 167 short-term general hospitals that participated in the Professional Activity Study of the Commission on Professional and Hospital Activities. Our results suggest that high-cost hospitalization can be characterized broadly by two groups: the single costly hospital episode and the multiple-admission pattern. We propose a theoretical framework to analyze high-cost hospitalization in terms of three dimensions: the magnitude of expenditures, the scope of high-cost illness within the cohort, and the scale of high-cost hospitalization within the population at large.