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Biomedical subjects

W B Schwartz

Publications and source records attributed to W B Schwartz.

At least 19 recordsLinked to original sources
PubMed1994

In the pipeline: a wave of valuable medical technology.

Technologic change has proceeded at a rapid pace during the past twenty years, and advances that are even more remarkable are in sight over the next decade. These changes will be driven largely by advances in molecular and cell biology, imaging techniques, and tissue engineering. Therapies directed toward causes rather than consequences of disease could conceivably produce inexpensive cures and thus slow the rise in medical costs. A more likely scenario envisions a continued rise in costs as advances in technology produce many expensive interventions that extend life but are not curative.

Autoimmune Diseases↗
PubMed1991

Hospital cost containment in the 1980s. Hard lessons learned and prospects for the 1990s.

BACKGROUND: A key strategy used to contain hospital costs during the 1980s was to reduce the total number of admissions and average lengths of stay. We assessed the magnitude of the savings achieved, the effect of the reductions on the rate of increase in costs, and the prospects for future savings through reductions in the number of days patients spend in the hospital (inpatient days). METHODS: Using data from the American Hospital Association and the Health Care Financing Administration, we calculated the savings in the total number of inpatient days as the deviation from the historical increase in the number of inpatient days per year. We then estimated the real increase in costs that would have been observed if the reduction in the number of inpatient days had not occurred; we defined this value as the "underlying" rate of increase in costs. Finally, we compared the rates of increase in hospital reimbursement for Medicare beneficiaries and patients not covered by Medicare (non-Medicare patients). RESULTS: The total number of inpatient days per year decreased by 28 percent, in aggregate, between 1981 and 1988. The annual reduction was greatest in 1984 and 1985 and became progressively smaller in each subsequent year; by 1988 there was virtually no further reduction in the total number of inpatient days. The brief slowing of the increase in costs in the mid-1980s can be attributed entirely to the reduction in the number of inpatient days per year. The underlying rate of increase in costs was thus unaffected by efforts to contain spending. An increased number of outpatient visits partially offset the savings that resulted from the reduction in the number of inpatient days. This increase persisted even when the savings due to the lower number of inpatient days dwindled, and it virtually eliminated any dollar savings during the latter part of the 1980s. Between 1976 and 1982, Medicare spending on services provided by acute care hospitals rose by 9.2 percent per year in real terms, whereas non-Medicare expenditures rose by only 4.6 percent. This pattern has been reversed in recent years; in 1987-1988, Medicare spending rose by only 0.6 percent per year, whereas non-Medicare spending rose by 9 percent. CONCLUSIONS: Our findings suggest that the era of easy reductions in the number of inpatient days, with the associated attenuation of rising costs, is largely over. If further reductions in inpatient days are accompanied by an increase in the amount of ambulatory care similar to that during the past few years, the net savings will probably be negligible. Once the potential savings due to reductions in the number of inappropriate inpatient days has been exhausted, real hospital costs can be expected to rise, unless other effective measures to contain costs are implemented.

Ambulatory Care↗
PubMed1990

Rationing health care: the choice before us.

Rapid technological advances and upward pressure on wages of hospital personnel are leading to a steady increase in health care spending that is absorbing an ever-larger fraction of gross national product. Eliminating inefficiencies in the system can provide brief fiscal relief, but rationing of beneficial services, even to the well-insured, offers the only prospect for sustained reduction in the growth of health care spending. The United States, which has negligible direct experience with rationing, can learn about choices it will face from the experience of Great Britain where health care has been rationed explicitly for many years.

Cost Control↗
PubMed1990

No evidence of an emerging physician surplus. An analysis of change in physicians' work load and income.

Analysis of physicians' work patterns and income between 1982 and 1987 provides strong evidence that the demand for physicians' services has risen at least as quickly as physician supply. Aggregate hours spent by US physicians who provide patient care rose by 21%, and aggregate real net income rose by more than 30% during a period in which the supply of physicians grew by only 16%. The aggregate number of visits rose by only 9%, indicating that the time spent per patient encounter rose sharply, presumably as a result of technological change and the increased complexity of care. Recently released data for 1988 are consistent with these trends. Our findings are inconsistent with the prediction by the Graduate Medical Education National Advisory Committee that there would be a large physician surplus by the year 1990. Moreover, if the upward trend in demand for physicians' services continues, as seems probable, a physician surplus should not develop in the foreseeable future. Only extensive rationing of beneficial services would be expected to alter this projection.

Data Collection↗
PubMed1989

Physicians who have lost their malpractice insurance. Their demographic characteristics and the surplus-lines companies that insure them.

The present study analyzes demographic data on 920 physicians who lost their coverage and applied to a "surplus-lines" company that insures essentially all applicants. Our analysis reveals that (1) some specialties are heavily overrepresented in the surplus-lines pool, (2) physicians aged 45 to 54 years are also overrepresented, (3) board certification is seen as frequently in the surplus-lines group as in the US physician population, and (4) the percentage of foreign medical graduates in the surplus-lines pool is virtually the same as that in the US physician population. A model of the actuarial process by which claims data can lead to termination of standard coverage suggests that disproportionate representation of high-risk specialties is not simply a function of a high average claims rate. We also show that, in contrast to joint underwriting associations, surplus-lines companies impose high premiums, large deductibles, and restrictions on practice, all of which are likely to reduce the frequency of negligent behavior.

Actuarial Analysis↗
PubMed1989

The role of physician-owned insurance companies in the detection and deterrence of negligence.

This study presents evidence that physician-owned insurance companies and their physician members play an important role in the detection and deterrence of negligent behavior. A survey of physician-owned companies indicates that 94% involve their physicians in one or more aspects of the underwriting process. About 60% involve their members in assessing the competence of physicians who have been sued and in advising the underwriters on decisions concerning both continued insurability and the conditions of insurance. During 1985, a total of 0.66% of the physicians in physician-owned companies had their insurance terminated or were forced to give up their coverage because of negligence-prone behavior. An additional 0.7% of active policyholders were subject to restrictions on practice or other medical sanctions and 1.8% to surcharges and deductibles. Thus, disciplinary actions were in place against 3.2% of insured physicians whose performance was viewed as in some way substandard. The findings indicate that the physician-owned companies are effective agents in identifying negligence-prone behavior, and suggest that these companies also play an important role in deterring substandard performance.

Clinical Competence↗
PubMed1988

Why there will be little or no physician surplus between now and the year 2000.

Most observers think that by the year 2000 there will be a considerable surplus of physicians in the United States. In this paper we present a new framework for estimating the future balance between supply and demand with respect to physicians' services. Our analysis suggests that even if competitive medical plans serve approximately half the population by the year 2000, there will probably be little or no physician surplus. Moreover, if a slight surplus should occur, it is likely to be largely erased by increased involvement of physicians in administrative activities and a variety of nontraditional clinical activities that currently occupy little of a physician's time. Our prediction of little or no surplus could be altered appreciably, however, by two forces that would have opposite effects: an acceleration of technological change would increase demand beyond our projections, whereas widespread rationing of beneficial services would constrain the demand for physicians' services.

Forecasting↗
PubMed1988

Are we training too many medical subspecialists?

As of 1983, 10% to 40% of cities with a population of 200,000 to 500,000 lacked a board-certified physician in one or more medical subspecialties, and many additional cities of this size had only one certified representative in many of the subspecialties. Somewhat smaller cities (population, 125,000 to 200,000) had far less complete coverage. Even when one includes board-certified internists who declared themselves subspecialists but lacked certification, there were many relatively large cities without complete coverage. Between now and 2000, an appreciable portion of the projected larger pool of board-certified subspecialists will be required to deal with a growing population and an increase in per capita demand for care. Others will locate in underserved or underserved cities, but our data suggest that even in 2000, many relatively large cities will have a deficit of most types of subspecialists.

Certification↗
PubMed1988

Artificial intelligence in medical diagnosis.

In an attempt to overcome limitations inherent in conventional computer-aided diagnosis, investigators have created programs that simulate expert human reasoning. Hopes that such a strategy would lead to clinically useful programs have not been fulfilled, but many of the problems impeding creation of effective artificial intelligence programs have been solved. Strategies have been developed to limit the number of hypotheses that a program must consider and to incorporate pathophysiologic reasoning. The latter innovation permits a program to analyze cases in which one disorder influences the presentation of another. Prototypes embodying such reasoning can explain their conclusions in medical terms that can be reviewed by the user. Despite these advances, further major research and developmental efforts will be necessary before expert performance by the computer becomes a reality.

Artificial Intelligence↗
PubMed1987

The inevitable failure of current cost-containment strategies. Why they can provide only temporary relief.

Current strategies for controlling hospital costs have focused primarily on eliminating care that is presumed to be of no medical value. These efforts have neglected the central fact that eliminating such care reduces current expenditures, but has little or no influence on three key factors responsible for the upward trend in real costs--population growth, rising input prices ("the hospital market basket"), and technologic innovation and diffusion. Aging of the population and the rising costs of malpractice insurance have received undue attention; together they can account for only three tenths of a percentage point in the upward trend. Gradual elimination of presumably useless care, perhaps as much as 30% of inpatient-days, can save many billions of dollars, but can only offset for a few years the forces causing costs to rise in US community hospitals. Indeed, in 1984, the reduction in patient days and resultant slowing in the real rate of rise to 2.1% appear simply to have concealed an underlying real rate of increase that was close to 7%. After all unnecessary days have been eliminated, the underlying rate of increase will reemerge unless limitations are placed on technologic innovation or beneficial services are rationed.

Cost Control↗
PubMed1985

Is the teaching hospital an endangered species?

The nonmunicipal teaching hospital faces some special challenges in adapting to the increasingly austere fiscal environment in which all hospitals must operate. However, except in a few instances, such developments as constraints on Medicaid expenditures do not appear to be notably more serious for teaching hospitals than for their community counterparts. The teaching hospitals most closely connected with medical schools provide more charity care and carry more bad debt than community hospitals. But other teaching hospitals have about the same burden as their community counterparts. The most serious problem facing teaching hospitals results from new bases of prospective reimbursement, some of which do not adequately compensate hospitals that treat more "difficult" cases--that is, more expensive cases. Competitive providers of health care such as health maintenance organizations promise to reduce admissions at all types of hospitals; whether this reduction will selectively affect teaching hospitals is not yet clear. By contrast, the fiscal state of municipal teaching hospitals is far more precarious than that of their nonmunicipal counterparts. The ability of these institutions to maintain high-quality patient care and teaching programs is in considerable jeopardy.

California↗
PubMed1985

Are fee-for-service costs increasing faster than HMO costs?

It is well known that the costs of care at health maintenance organizations (HMOs) at any point in time have been lower than in the fee-for-service sector, but how costs have changed in each of these sectors has been less well-documented. The only previous study, which examined the HMO experience during the 1960s and early 1970s, found that HMO and fee-for-service costs rose at approximately the same rate. The present study, which extends this analysis to the period 1976-1981, also demonstrates that HMO costs increased at a rate not detectably different from that in the fee-for-service sector. These results are consistent with the earlier conclusions that HMOs cause a once-and-for-all reduction in cost. They also indicate that the public has been willing to pay for much of the increased costs of modern medical technology. Key words: fee-for-service; health maintenance organizations; Rand Health Insurance Study; Group Health Cooperative data.

Capitation Fee↗