Abstract:
OBJECTIVE:To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE:Medicare administrative claims for 1994 and 1995. STUDY DESIGN:We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS:The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS:Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS:More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.
journal_name
Health Serv Resjournal_title
Health services researchauthors
Buntin MB,Garber AM,McClellan M,Newhouse JPdoi
10.1111/j.1475-6773.2004.00218.xkeywords:
subject
Has Abstractpub_date
2004-02-01 00:00:00pages
111-30issue
1eissn
0017-9124issn
1475-6773journal_volume
39pub_type
杂志文章abstract:OBJECTIVE:To examine the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. DATA SOURCES/STUDY SETTING:Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that imp...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2004.00260.x
更新日期:2004-08-01 00:00:00
abstract:OBJECTIVE/PURPOSE:To stimulate discussion within the research and policy community about the value of and issues surrounding different ways to describe access to care in a health system reconfigured by the growth of managed care, competition, and other marketplace changes. PRINCIPLE FINDINGS:The concept of access has ...
journal_title:Health services research
pub_type: 杂志文章,评审
doi:
更新日期:1998-08-01 00:00:00
abstract:OBJECTIVE:To examine the implications of serious and chronic health problems on the willingness of enrollees to switch health plans if they are dissatisfied with their current arrangements. DATA SOURCE:A large (20,283 respondents) survey of employees of three national corporations committed to the model of managed com...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1999-06-01 00:00:00
abstract:OBJECTIVE:To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures. STU...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1998-08-01 00:00:00
abstract:OBJECTIVE:To use statistical process control charts to monitor in-hospital outcomes at the hospital level for a wide range of procedures and diagnoses. DATA SOURCES:Routine English hospital admissions data. STUDY DESIGN:Retrospective analysis using risk-adjusted log-likelihood cumulative sum (CUSUM) charts, comparing...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2007.00742.x
更新日期:2008-02-01 00:00:00
abstract:OBJECTIVE:Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems....
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12340
更新日期:2016-04-01 00:00:00
abstract:OBJECTIVE:To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures. DATA SOURCE:Secondary data analysis of Medicare claims data (1999-2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of t...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2006.00509.x
更新日期:2006-06-01 00:00:00
abstract::Properties of the inverse gaussian distribution are presented with comments on fitting the distribution to lentgh-of-stay data. A conceptual framework for the hospitalization process is described; it suggests that the inverse gaussian distribution has considerable potential as both a descriptive and prescriptive model...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1975-10-01 00:00:00
abstract:OBJECTIVE:To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. DATA SOURCES:The primary data consisted of longitudinal information on comorbid co...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2005.00461.x
更新日期:2006-02-01 00:00:00
abstract:OBJECTIVE:To test whether nonprofit, for-profit, or government hospital ownership affects medical service provision in rural hospital markets, either directly or through the spillover effects of ownership mix. DATA SOURCES/STUDY SETTING:Data are from the American Hospital Association, U.S. Census, CMS Healthcare Cost ...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2011.01280.x
更新日期:2011-10-01 00:00:00
abstract::In this paper I propose a methodology for paying short-term general hospitals on the basis of prospective cost-based case-mix revenue budgets. A hospital's budget is divided into patient care--related components and other components. The patient care--related budget is based on the case mix of patients treated by the ...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1980-07-01 00:00:00
abstract::Arthroscopic surgery of the knee has reduced in-hospital utilization of 37 percent for surgical treatment of internal derangements of the knee at The Mount Sinai Medical Center. In a study comparing arthrotomies of the knee in 1974 (N = 106) to arthroscopic surgery of the knee in 1984 (N = 221) it was found that while...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1989-12-01 00:00:00
abstract:OBJECTIVE:To compare the estimated effects of dialysis center profit status on patient survival using alternative estimation strategies with retrospective data. DATA SOURCES/STUDY SETTING:Patient and provider-level retrospective data from the United States Renal Data System (USRDS), 1996-1999. STUDY DESIGN:Observatio...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2006.00581.x
更新日期:2006-12-01 00:00:00
abstract:OBJECTIVE:To explore state patterns in the racial life expectancy gap. DATA SOURCES:The 1997-2004 Multiple Cause of Death PUF, 2000 U.S. Census. STUDY DESIGN:We calculated life expectancy at birth for black and white men and women. DATA EXTRACTION METHODS:Data were obtained by the NCHS and U.S. Census Bureau. PRINC...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2011.01345.x
更新日期:2012-02-01 00:00:00
abstract::This review summarizes the capabilities and contributions of quantitative sector models for understanding trends in hospital expenses and the effects thereon of various public policies. After some brief historical notes on the use of analogous models in other policy areas, the general classes of national, partial, and...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1985-02-01 00:00:00
abstract:OBJECTIVES:To examine variation in risk-adjusted reinsurance payments across Part D plans, analyze its implications for the program, and explore options to reduce reinsurance payments. DATA/STUDY DESIGN:2007-2015 Part D Plan Payment and Premium data; 2010-2013 Part D Prescription Drug Event data; and 2013 Part D Plan ...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12866
更新日期:2018-12-01 00:00:00
abstract:OBJECTIVE:To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs). DATA SOURCES:Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Ass...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12032
更新日期:2013-08-01 00:00:00
abstract:OBJECTIVE:To assess the value of a novel composite measure for identifying the best hospitals for major procedures. DATA SOURCE:We used national Medicare data for patients undergoing five high-risk surgical procedures between 2005 and 2008. STUDY DESIGN:For each procedure, we used empirical Bayes techniques to create...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2012.01407.x
更新日期:2012-10-01 00:00:00
abstract:OBJECTIVE:This study investigated whether unexpected length of stay (LOS) could be used as an indicator to identify hospital patients who experienced complications or whose care exhibited low adherence to normative practices. DATA SOURCES AND STUDY SETTING:We analyzed 1,477 cases admitted for one of three medical cond...
journal_title:Health services research
pub_type: 杂志文章,评审
doi:
更新日期:1995-10-01 00:00:00
abstract:OBJECTIVE:To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expande...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2011.01249.x
更新日期:2011-08-01 00:00:00
abstract::Two indexes are described, based on measures of administrative effectiveness and patient care effectiveness. The measures used were selected and ranked by a Delphi panel from a list of 30 measures drawn from the literature. Weights were assigned by the panel to 19 selected measures. The resulting indexes did well in a...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1976-10-01 00:00:00
abstract:OBJECTIVE:To describe changes in characteristics of directors of outpatient opioid agonist treatment (OAT) programs, and to examine the association between directors' characteristics and low methadone dosage. DATA SOURCE:Repeated cross-sectional surveys of OAT programs in the United States from 1995 to 2011. STUDY DE...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12558
更新日期:2017-10-01 00:00:00
abstract:OBJECTIVE:To analyze differences in the determination of healthcare expenditures among racial/ethnic groups. DATA SOURCE:The 1987 National Medical Expenditure Survey, a nationally representative sample of the United States population. (Nomenclature reflects racial/ethnic categories as used in the Survey.) STUDY DESIG...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1998-10-01 00:00:00
abstract:OBJECTIVE:To assess the association between aggregate unemployment and hospital discharges for acute myocardial infarction (AMI) among adults and seniors, 1995-2011. DATA SOURCES/STUDY SETTING:Community hospital discharge data from states collected for the Healthcare Cost and Utilization Project (HCUP) State Inpatient...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12298
更新日期:2015-10-01 00:00:00
abstract:OBJECTIVE:To examine the effect of the Medicare prospective payment system (PPS) for skilled nursing facilities (SNF) on the delivery of rehabilitation therapy to residents. DATA SOURCES:Resident-level data are based on the Resident Assessment Instrument Minimum Data Set for nursing facilities. All elderly residents a...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2004.00291.x
更新日期:2004-10-01 00:00:00
abstract:OBJECTIVE:To quantify between-unit variability in mean length of stay (LoS) between intensive care units (ICUs) after adjusting for differences in case mix using a method that does not require arbitrary trimming of data. SETTING:An analysis of registry data from pediatric ICUs (PICUs) in Australia and New Zealand. ST...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/j.1475-6773.2012.01421.x
更新日期:2012-12-01 00:00:00
abstract::Using existing data sources, we developed three risk-adjusted measures of hospital quality: the risk-adjusted mortality index (RAMI), the risk-adjusted readmissions index (RARI), and the risk-adjusted complication index (RACI). We describe the construction and validation of each of these indexes. After these measures ...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1991-10-01 00:00:00
abstract::A model is described that predicts hospital census and computes, for each day, the number of elective admissions that will maximize the census over the short run, subject to constraints on the probability of overflow. Where a computer is available the model provides detailed predictions of census in units as small as ...
journal_title:Health services research
pub_type: 杂志文章
doi:
更新日期:1977-01-01 00:00:00
abstract:OBJECTIVE:To assess what is known about the relationship between patient experience measures and incentives designed to improve care, and to identify how public policy and medical practices can promote patient-valued outcomes in health systems with strong financial incentives. DATA SOURCES/STUDY SETTING:Existing liter...
journal_title:Health services research
pub_type: 杂志文章,评审
doi:10.1111/1475-6773.12420
更新日期:2015-12-01 00:00:00
abstract:OBJECTIVE:This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). DATA SOURCE:Medicare Part A (inpatient) and Part B (office visit) claims for 20...
journal_title:Health services research
pub_type: 杂志文章
doi:10.1111/1475-6773.12425
更新日期:2016-08-01 00:00:00