Showing papers in "Health Services Research in 1985"

Seven reasons why it is so difficult to make community-based long-term care cost-effective.

Abstract: A decade of research on home- and community-based long-term care shows that few of the assumptions behind expectations of tis potential cost-effectiveness were warranted. Few who use home- and community-based long-term care would otherwise have been long-stayers in nursing homes. Long-stayers tend to be older, sicker, more dependent, and poorer in social resources than those who use community care. Fewer still who use community care actually have their institutional stay averted or shortened by its use, even if they are at risk. But more effective targeting on those most likely to be institutionalized may lead to high screening costs and small, inefficient programs, because few patients in the community fit the profile for high risk of institutionalization. Conversely, the very sickest and most dependent patients may be cheaper to serve in a nursing home than in the community. Patient outcome benefits have also been limited: except for the higher contentment levels found in some studies, community care appears to produce no special outcome benefits in longevity, physical or mental functioning, or social activity levels. Nonetheless, community care serves a sick, dependent, and--most people would agree--deserving population of patients and their caretakers. A refocusing of public policy to target specifically on the functionally dependent rather than the aged per se may be the best hope for public support for community care.

Cost savings in hospice: final results of the National Hospice Study.

Abstract: Medicare inpatient and home care costs over the last year of life of terminal cancer patients served in two types of hospices and in conventional care (CC) were compared as a part of the National Hospice Study (NHS). Both home care (HC) and hospital-based (HB) hospice patients had lower costs in the last month of life than did CC patients. HC patients substituted home care for inpatient care, yielding cost savings for lengths of hospice stay of up to 1 year. Although HB patients added home care to relatively high levels of inpatient care, their ancillary costs per inpatient day were significantly lower than those of CC patients. Thus, HB costs over the last year of life were also somewhat less than those of CC. The size of the savings associated with hospice care is sensitive to the type of hospice and the length of stay distribution of patients served; patients served longer have significantly higher costs in the last year of life.

Organizational stress in the hospital: development of a model for diagnosis and prediction.

Abstract: A model of organizational stress in the hospital was developed and tested. The model utilized measures of organizational climate, supervisory practices, and work group relations as predictors of the amount of role conflict and ambiguity that nurses perceived in providing patient care. Role conflict and ambiguity were treated as variables that intervene between organizational variables and the level of stress that the nursing staff experienced. Nursing stress was viewed as a direct cause of job dissatisfaction and as an indirect cause of absenteeism among the nursing staff. Data from 158 registered nurses, licensed practical nurses, and nursing assistants on seven nursing units in a 1,160-bed private teaching hospital were used to estimate the parameters of a structural equation model. The model was used to predict the results of a survey feedback project designed to change the supervisory style used on the units. Pre- and posttest data from four surgical units were used to validate the model. The findings suggest that, as predicted, supervisory practices that led to more open expression of views and joint problem solving resulted in reduced role conflict, ambiguity, and stress; increased job satisfaction; and lower levels of absenteeism among the nursing staff.

Hospital bed utilization: an implemented simulation approach to adjusting and maintaining appropriate levels.

Abstract: A simulation model was constructed to permit detailed assessment of bed allocation and usage rules, thereby easing considerably the process of improving and maintaining appropriate utilization levels. The model, written in Simscript II.5, follows patient processing from preadmission through discharge, uniquely identifying patients, beds, diagnosis-related service areas, and so on, permitting reliable evaluation of bed usage performance. It was applied at The Mount Sinai Hospital, New York City. Using the model, several bed allocation plans were developed, one being adopted as the best-case reallocation. Also studied was the impact of severely restricting off-service patient placements. Additionally, the work resulted in a new service being established, a realignment of elective admissions reservations, and the incorporation of an additional measure of performance. The article discusses bed utilization problems in general and, in particular, the simulation model, the performance measures used, the experiments undertaken, the results achieved, the then-current and best-case allocation plans, and some directions for future work.

Apples and oranges? A review of evaluations of community-based long-term care.

Abstract: This article synthesizes the contradictory findings of the community-based long-term care evaluation literature by grouping 13 studies into three models of care tested All studies are reviewed according to tenets of internal and external/construct validity to ascertain what is "known" and "not known" about the effectiveness of this new type of care, and to specify areas needing further research Findings suggest that increased preoperational specification of underlying theory, increased sophistication in targeting services to high-risk groups, use of multivariate analysis, and the development of more relevant outcome measures will improve the quality of future study findings, thereby contributing to theory and model building in this field

Independent versus system-affiliated hospitals: a comparative analysis of financial performance, cost, and productivity.

Abstract: This article analyzes differences in the financial performance, cost, and productivity between system-affiliated and independent hospitals. Data for the study were obtained from the 1981 American Hospital Association (AHA) Annual Survey of Hospitals for the State of Iowa and included 94 nonstate or nonfederal short-term hospitals without long-term care units. An interpretation of the results indicated that system-affiliated hospitals are more profitable, have better access to capital markets, are more effective price setters, and experience higher costs per case which are related to longer lengths of stay and less productive use of plant and equipment in generating revenues.

Economic regulation and hospital behavior: the effects on medical staff organization and hospital-physician relationships.

Abstract: New forms of payment, growing competition, the continued evolution of multiunit hospital systems, and associated forces are redefining the fundamental relationship between hospitals and physicians. As part of a larger theory of organizational response to the environment, the effects of these external forces on hospital-medical staff organization were examined using both cross-sectional data and data collected at two points in time. Findings suggest that regulation and competition, at least up to 1982, have had relatively little direct effect on hospital medical staff organization. Rather, changes in medical staff organization are more strongly associated with hospital case mix and with structural characteristics involving membership in a multiunit system, size, ownership, and location. The pervasive effect of case mix and the consistent effect of multiunit system involvement support the need for policymakers to give these factors particular attention in considering how hospitals and their medical staffs might respond to future regulatory and/or competitive approaches.

Hospital DRGs and the need for long-term care services: an empirical analysis.

Abstract: The Medicare DRG-based Prospective Payment System (PPS) encourages hospitals to reduce length of stay for elderly patients. Thus, discharges to long-term care services are expected to increase. Maryland hospital data for 1980 are used to identify those DRGs which most frequently represent patients discharged to nursing home and home health care services; explores the incentive to discharge earlier under PPS those patients needing long-term care versus short-term care; and describes characteristics of patients most likely to face increased pressure of earlier discharge to nursing homes and home health programs. Because only a limited set of patient characteristics are available from Maryland hospitals, data from a study of San Diego nursing homes are used to explore further the sociodemographic and health status measures associated with unusually long stays in a hospital prior to nursing home placement. This research suggests that the DRG reimbursement system gives hospitals a strong incentive for earlier discharge of patients needing long-term care services. However, hospitals that target only long-term care patients for early discharge will not substantially gain under PPS because these patients represent a small portion of the cases treated in the hospital and a small percentage of unreimbursed days.

The extent of physician participation in Medicaid: a comparison of physician estimates and aggregated patient records.

Abstract: This article compares two measures of the extent of physician participation in Medicaid programs The first, which has been used in most research to date on the subject, is based on physician estimates of the proportion of their patients who are Medicaid patients The second derives from encounter forms for a sample of visits to the interviewed physicians The comparison shows that physicians in the sample tended to overestimate by 40 percent the extent of their Medicaid participation Because the two measures are highly correlated, the analysis of the determinants of Medicaid participation was not affected by the measure used However, since physicians tended to overstate the proportion of Medicaid patients in their practices, interview data should not be used to measure the amount of physician participation or to calculate elasticities for the effects of policy changes on the extent of participation

Service areas for ambulatory medical care.

Abstract: This article evaluates three alternative definitions of physician service areas using data from the 1978 National Health Interview Survey. The three types of areas are county aggregations based on different data sources: the Bureau of Economic Analysis Economic Areas (BEAAs), Ranally Basic Trading Areas (RBTAs), and Health Care Commuting Areas (HCCAs). The three types of areas differ substantially in size, population, urbanization, and the availability of physicians. The overall percentage of physician visits outside each of the three areas was small, ranging from 3 percent for BEAAs to 5 percent for RBTAs and HCCAs. Visits by nonmetropolitan residents were about four times as likely as those by metropolitan residents to occur outside of each area. The results suggest that HCCAs are the most appropriate primary care physician service areas because they are the smallest in size and population and have the greatest variability in physician supply, yet they exhibit an amount of outside-area travel for care similar to that of the two larger types of areas.

Visits to the physician: an evaluation of the usual-source effect.

Abstract: Having a regular or usual source for medical care has frequently been found to be an important correlate of ambulatory visits to the physician. However, it remains unclear whether having a usual source is a determinant of visits, a consequence of visits, or both. This article addresses the question, how do these alternative theoretical relationships affect estimates of the relative impact of having a usual source on illness-related visits? The empirical results of a household interview survey generally support the significance of a usual-source variable as a determinant of illness-related visits, but they indicate that use of a single equation-estimation technique may overestimate the magnitude of this effect.

Cost-effectiveness implications based on a comparison of nursing home and home health case mix.

Abstract: Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.

Census tract predictors of physical, psychological, and social functioning for needs assessment.

Abstract: The advantages of census data-based needs assessment cannot be fully realized in the absence of demonstrated relationships between area characteristics and aggregate individual service need. This study sought to ascertain these relationships by using tract characteristics from the 1980 census to predict tract aggregate levels of individually measured social, physical, and psychological functioning. A census tract stratified sample of 3,465 permanent households in eastern Long Island, New York was used for the study. In each household, a randomly selected adult was surveyed regarding physical functioning, depressed mood, and social isolation. Stepwise multiple regression was used to determine which census variables best predicted the tract distributions of each of the functioning measures. Census variables explained from 23 to 30 percent of the variance in tract need level. Study findings have immediate utility for efficient needs assessment and suggest avenues for future improvement of needs assessment methods.

Clinical profiles of hospital discharge rates in local communities.

Abstract: Using comprehensive 1980 data for hospitalization of the 9 million citizens of Michigan's lower peninsula, the authors have previously demonstrated that the discharge rates of local communities differ by a range of 2 to 1 This article seeks to identify differences in the clinical profile of high-use compared to low-use communities Population-based rates and percentages of total discharges were studied for major clinical activity groups, such as cardiovascular disease, frequent diagnoses, rarely occurring diagnoses, short- and long-stay diagnoses, certain surgical procedures, and major organ groups of the diagnostic classification system Although high-use communities tend to admit proportionately fewer surgical cases and proportionately more nonsurgical cases, few other such patterns could be demonstrated

Multi-institutional arrangements: relationships between governing boards and hospital chief executive officers.

Abstract: This investigation focuses on the impact of multi-institutional arrangements on the role of governing boards in limiting or enhancing the managerial autonomy of individual hospitals. Data from a 1979 Special Survey by the American Hospital Association (N = 4213) are used to examine governing board-administrator relationships as a function of the degree of autonomy and scope of responsibility of the hospital governing board. It is hypothesized that governing boards responsible for multiple hospitals or for multiple nonhospital organizations and those boards accountable to a higher organizational authority will exercise more formal control over hospital chief executive officers (CEOs) than will boards of single or autonomous hospitals. The analysis assumes that formal control by the governing board over the management function of the individual hospital is exercised partly through soliciting or limiting participation by hospital administrators in key policy decisions and through the evaluation of administrative performance. Therefore, it is anticipated that hospitals governed by boards with multiple responsibilities as well as hospitals governed by boards accountable to a higher authority will be (1) less likely to have CEOs who are members of the governing board executive committee, (2) more likely to have annual performance reviews of the CEO by the governing board, and (3) more likely to have such reviews conducted according to preestablished criteria. Study results provide general support for the hypotheses with respect to hospital boards with multiple responsibilities: the data suggest that such boards do exercise greater control over hospital administrators and these effects do appear to be stronger for hospitals in the private sector. Hospitals governed by boards accountable to a higher authority, however, are more likely to have CEOs who are members of the governing board executive committee--a pattern in direct opposition to that hypothesized. Furthermore, these boards are no more likely to conduct annual CEO performance reviews than are boards with more autonomy. Boards accountable to higher authorities are more likely, however, to use preestablished criteria when such reviews are conducted. This general pattern is similar whether hospital boards are accountable to religious authorities, to investor-owned corporate boards, or to the boards of not-for-profit multi-institutional systems. A different pattern emerges, however, for boards accountable to a state, county, or local government authority.(ABSTRACT TRUNCATED AT 400 WORDS)

Assessing the financial characteristics of multi-institutional organizations.

Abstract: The prospective pricing of health services is precipitating greater attention to financial characteristics and greater development of multi-institutional organizations (MIOs). This study compares the financial characteristics of 1,590 MIO hospitals with 2,819 freestanding hospitals by ownership type: church-operated, other not-for-profit, and investor-owned. Using 1981 data from the American Hospital Association, the hospitals' capital structure and profitability are measured using three financial ratios: total assets-to-equity, return on equity, and operating margin. The results indicate both greater leverage and greater profitability among MIO hospitals, particularly in the investor-owned sector. The implications of these findings are discussed relative to financial performance by hospital ownership type in the future.

Factors associated with variation in financial condition among voluntary hospitals.

Abstract: This article uses multiple regression analysis to identify factors which affect variations in the financial condition of voluntary hospitals in New York State. Six separate ratios are used to measure financial condition and 18 independent variables are considered. The factors affecting financial conditions were found to vary among dimensions of financial health, and different causal relationships were evident among hospitals in New York City than among those in the rest of the state.

Health care under AHCCCS: an examination of Arizona's alternative to Medicaid.

Abstract: In late 1982, as an alternative to Medicaid, Arizona implemented a prepaid, competitively bid medical care program--the Arizona Health Care Cost Containment System (AHCCCS) Before its introduction, the poor had been cared for primarily by a network of county-supported centers Impact of the AHCCCS initiative was examined by surveying comparable samples of poor persons in pre-AHCCCS 1982, and in 1984, after the program was in place Both before and since AHCCCS, Arizona has had very restrictive eligibility requirements; to examine the program's impact on both eligible persons and the so-called "notch" group, the samples consist of individuals with family incomes within 200 percent of the program's financial criterion Telephone surveys revealed that overall a lower proportion of the poor were enrolled in AHCCCS in 1984 than participated in county programs in 1982 However, access to care increased for AHCCCS enrollees in 1984, compared to county patients in 1982--and a greater proportion of 1984 AHCCCS enrollees than their 1982 counterparts in the county programs had at least one medical encounter in the 12 months preceding the surveys For its enrolled population, then, AHCCCS may be a viable alternative to conventional Medicaid programs and to previous efforts at providing care at county sites But the poor financially ineligible for AHCCCS are experiencing decreased opportunities for health services The conclusions address the policy implications of the findings

Profit incentives and the hospital industry: are we expecting too much?

Abstract: In the recent past, a great deal of faith has been placed in the idea that the performance of the hospital industry could be improved significantly by relying more heavily on profit incentives. This article considers the effect of profit incentives on hospital behavior and finds that the existence of profit incentives has not led the for-profit hospitals in the sample to behave in significantly different economic fashions than the nonprofits.

Forecasting demand for long-term care services.

Abstract: This article analyzes three methods used to forecast the transition of long-term care clients through a variety of possible home and facility placements and levels of care. The test population (N = 1,653) is derived from the larger population of clients admitted in 1978 to British Columbia's newly established Long-Term Care program. The investigators have accumulated 5 years of service-generated data on moves, discharges, and deaths of these clients. Results show that the first-order Markov chain with stationary transition probabilities yields a superior forecast to state-by-state moving average growth and state-by-state regression analyses. The results of these analyses indicate that the Markov method should receive serious consideration as a tool for resource planning and allocation in long-term care.

Validation of the patient roster in a primary care practice.

Abstract: Knowledge of the size of a practice population is an essential base for the evaluation of new forms of health care delivery and for epidemiologic research in primary care. Remuneration to providers in Ontario's Health Service Organization and Health Centre programs is partially based on the number of people listed on the patient roster as members of the practice. However, the accuracy of these rosters has never been determined. A mail and telephone survey was conducted to validate the roster in one such health center. A random sample of 1,065 households was contacted and a 78 percent response rate was obtained. The practice roster showed a population of 3,134. The age- and sex-adjusted estimate from the survey was 2,964 (+/- 262) individuals. The sensitivity, specificity, and accuracy of the roster were 0.90 or greater. It is concluded that this particular roster is a valid indicator of practice size, but caution is expressed about generalizing these results to other practices.

An application of statistical matching with the survey of income and education and the 1976 Health Interview Survey.

Abstract: This article outlines an alternative procedure to household surveys for obtaining individual observation-level data. The procedure, called statistical matching, integrates data on an individual observation from one source with data on a different observation identified as the "best matching" or "most similar" record from a second source. The best match is determined by objective statistical criteria. Also reported is a significant application of the procedure between the Survey of Income and Education and the 1976 National Health Interview Survey. The success of merging these two large, nationally representative data files shows statistical matching as a viable method of creating databases for health services research.

An analysis of competitive bidding by providers for indigent medical care contracts.

Abstract: This article develops a model of behavior in bidding for indigent medical care contracts in which bidders set bid prices to maximize their expected utility, conditional on estimates of variables which affect the payoff associated with winning or losing a contract. The hypotheses generated by this model are tested empirically using data from the first round of bidding in the Arizona indigent health care experiment. The behavior of bidding organizations in Arizona is found to be consistent in most respects with the predictions of the model. Bid prices appear to have been influenced by estimated costs and by expectations concerning the potential loss from not securing a contract, the initial wealth of the bidding organization, and the expected number of competitors in the bidding process.

Task and structural correlates of organizational effectiveness in private psychiatric hospitals.

Abstract: This exploration of the relationships between task and structural variables and two dimensions of organizational effectiveness in 76 private psychiatric hospitals revealed that high levels of centralization were associated with patient care effectiveness. High levels of centralization and formalization were associated with administrative effectiveness. An enhancing effect of organizational structure is suggested as contributing to organizational effectiveness.

Intervention strategies for children: a research agenda.

Abstract: This background review has attempted to pinpoint problems and issues of intervention strategies to promote health among children. Some traditional interventions as they are now provided in preventive service packages, for example, are critically assessed; new interventions like neonatal intensive care, prenatal diagnosis, periconceptional vitamin supplementation, and nutritional supplementation during later pregnancy are welcome; supportive outreach services through nurse home visitors to bring proved technologies to those in greatest need, while they may not be new have shown renewed effectiveness. Recently recognized problems like the "new morbidity," and newly recognized prevention potentials like the great prospects for accident prevention, adequate school health programs, and special adolescent care programs are promising areas for preventive services effectiveness. We do not claim that a comprehensive list has been presented. Rather, an attempt has been made to challenge some traditional preventive techniques, e.g., preoperative x-rays, to stimulate thinking about new organizational forms of care delivery, and to keep an open agenda. As a result, the reader will feel a "lack of closure"--challenges without definitive answers. The general assertion is that personal preventive care is only weakly related to health and that preventive care delivery is not a simple technical problem. Let me summarize the main points. First, the lack of evidence and comprehensiveness. Other reviews of preventive care packages could have been discussed. The presentation by Fielding [164] in the Institute of Medicine's background papers to Healthy People also includes service listings for pregnant women, normal infants, preschool children, schoolchildren, and adolescents. The Lifetime Health-Monitoring program by Breslow and Somers [165] set goals and services that have already become practice patterns for large parts of the country. Many more cost-effectiveness studies of immunizations and screenings could have been cited. The point, however, is not whether technologies with the potential for prevention exist, but whether these technologies have been used and are now used effectively for that purpose, and whether their performance in the real world represents the best use of scarce and expensive resources. Scientific evidence of organized delivery effectiveness is rare.(ABSTRACT TRUNCATED AT 400 WORDS)