Volume/outcome relationships in small rural hospitals.

This article summarizes a study of relationships between hospital volume and patient outcomes for diagnoses commonly treated and procedures commonly performed in smaller rural hospitals. Literature review findings and results of analyses using secondary data for several conditions suggest few if any volume/outcome relationships (with mortality being the main outcome for which data were available). A basic finding of the study is that most conditions and procedures for which volume effects on mortality have been found typically do not pertain to small rural hospitals. However, the available secondary data are weak, and many conditions and procedures have not been studied for small rural hospitals. Therefore, continued monitoring and review are important, as well as improved data systems, further research, and information dissemination on volume/outcome relationships. In particular, examining relationships between volume and outcomes in addition to mortality is critical to a thorough understanding of this topic.

Case mix of home health patients under capitated and fee-for-service payment.

OBJECTIVE: We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN: A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS: Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA: Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES: The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS: (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS: The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences.

Patient-level cost of home health care under capitated and fee-for-service payment.

This article examines costs for a national sample of 1,260 Medicare patients receiving home health care from 38 home health agencies. It uses data from a study that compares home health care provided to Medicare beneficiaries in health maintenance organizations (HMOs) and the traditional fee-for-service (FFS) system. The major findings indicate significantly lower costs, based on fewer home health visits, for HMO patients compared to FFS patients, even after adjustment for case mix and other factors. However, FFS patients also attain better outcomes, suggesting that HMOs may provide too few visits to home health patients. At the same time, the number of visits to FFS patients may be greater than is necessary to achieve the better FFS outcomes.

Home health agency quality: Medicare certification findings compared to patient outcomes.

As part of an evaluation of the Medicare certification program for home health agencies (HHAs), we examined the extent to which certification findings were related to patient outcomes. In a previous study, we collected longitudinal patient data for a national sample of 42 HHAs and developed precise patient outcome measures. In this study, the outcome measures were compared to certification findings for the same HHAs and time period (1991-93). We found relatively little association between the two sets of measures. The findings indicate that the Medicare HHA survey process does not yet successfully incorporate patient outcomes.

Quality of care in teaching nursing homes: findings and implications.

This article explores policy implications and selected methodological topics relating to long-term care (LTC) quality. We first discuss the Teaching Nursing Home Program (TNHP), in which quality of care in teaching nursing homes (TNHs) was found to be superior to the quality of care in comparison nursing homes (CNHs). A combination of outcome and process/structural measures was used to evaluate the effects of care and underlying reasons for superior TNH outcomes. Second, we explore policy and analytic ramifications. Conceptual, methodological, and applied issues in measuring and improving the quality of LTC are discussed in the context of TNH research and related research in home care.

Home health care outcomes under capitated and fee-for-service payment.

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.

Measuring and assuring the quality of home health care.

The growth in home health care in the United States since 1970, and the exponential increase in the provision of Medicare-covered home health services over the past 5 years, underscores the critical need to assess the effectiveness of home health care in our society. This article presents conceptual and applied topics and approaches involved in assessing effectiveness through measuring the outcomes of home health care. Definitions are provided for a number of terms that relate to quality of care, outcome measures, risk adjustment, and quality assurance (QA) in home health care. The goal is to provide an overview of a potential systemwide approach to outcome-based QA that has its basis in a partnership between the home health industry and payers or regulators.