Use of utilization management methods in State Medicaid programs.

This article describes the use of utilization management (UM) methods by State Medicaid programs. The use of optional UM methods range from zero in one State to eight in four States, with a median of five. A majority of States have programs for ambulatory surgery, preadmission certification, lock-in, primary-care case management, and targeted case management. Overall, no UM method was judged by States to have an adverse effect on access of quality of care. For UM methods mandated by the Medicaid program, more than one-third of the States rated physician certification as minimally effective.

Medicare-covered skilled nursing facility services, 1967-88.

The skilled nursing facility benefit under Medicare has been difficult to administer because its intent has been subject to misinterpretation. This article describes the series of legislative and administrative actions taken to align the benefit's use with its intent. Data are presented to show the changes in utilization and program expenditures in response to the actions taken. The 1988 clarifications to the level-of-care requirements seem to have resulted in an increased level of use of skilled nursing facility services.

Use of Medicare-covered home health agency services, 1988.

From 1974 through 1983, Medicare-covered home health visits and expenditures increased at double digit rates (18.4 and 29.0 percent annually, respectively). During the period from 1984 through 1987, intensified bill review by fiscal intermediaries and increased denial rates led to a decline in the number of home health visits. New reimbursement policies led to a markedly reduced rate of increase in the payments for home health services. By 1988, the use of and expenditures for home health services resumed rising. In this article, the trends in home health service use and expenditures are presented and the changes in legislation and policies that affected them are discussed.

Swing-bed services under the Medicare program, 1984-87.

Under Medicare, swing beds are beds that can be used by small rural hospitals to furnish both acute and post-acute care. The swing-bed program was instituted under the provisions of the Omnibus Reconciliation Act of 1980 (Public Law 96-499). Under Medicare, post-acute care in the hospital would be covered as services equivalent to skilled nursing facility level of care. Data show that the program has had a rapid rate of growth. By 1987, swing beds accounted for 9.7 percent of the admissions to skilled nursing facility services, 6.0 percent of the covered days of care, and 6.2 percent of the reimbursements. Over one-half of the swing-bed services are furnished in the North Central States.

Evaluation of the national swing-bed program in rural hospitals.

The Health Care Financing Administration (HCFA) implemented a swing-bed demonstration and evaluation program for rural communities in the 1970's. The demonstration substantiated the cost effectiveness of providing long-term care in small, rural, acute care hospitals. As a result, Section 904 of the Omnibus Reconciliation Act of 1980 (Public Law 96-499) authorized the national swing-bed program, allowing rural hospitals with fewer than 50 beds to provide Medicare- and Medicaid-covered swing-bed care. A congressionally mandated evaluation of the program was conducted and the national swing-bed program was found to be cost effective. In this article, HCFA's report and recommendations to Congress are summarized in the context of the evaluation findings. HCFA recommended that the program be continued and that consideration be given to extending the option to larger hospitals. In this regard, the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) extended the program to include rural hospitals with up to 100 beds.

Outpatient prescription drug utilization and expenditure patterns of noninstitutionalized aged Medicare beneficiaries.

The goal of the National Medical Care Utilization and Expenditure Survey (NMCUES) of 1980 was to improve the understanding of the ways in which Americans use and pay for health care. This report is one in a series of descriptive reports based on NMCUES data. This report provides data regarding prescription drugs obtained on an outpatient basis by noninstitutionalized elderly people who reported being covered by Medicare in 1980. The results presented are based on NMCUES data collected about the civilian noninstitutionalized persons in the NMCUES national household sample who at any time during the survey year of 1980: (1) were 65 years of age or over, and (2) reported having been covered by Medicare hospital insurance (HI) or Medicare supplementary medical insurance (SMI) or both. These results include the number of prescriptions obtained during the survey year, the total charges for these prescriptions, the amounts paid by various sources, and the types of drugs obtained. Noninstitutionalized aged Medicare beneficiaries obtained an estimated 288 million prescriptions during 1980 and spent an estimated $2.3 billion for prescription drugs. Four of five beneficiaries used prescription drugs during the year. Although aged Medicare beneficiaries represented only 10.9 percent of the U.S. population during 1980, they accounted for 28.6 percent of all prescriptions and 30.2 percent of total prescription drug charges. The average aged beneficiary during the year purchased 12.1 prescriptions and incurred $98 of expenditures, about three times the average of those under 65 years of age. The average charge per prescription was $8.05. Prescription drug charges accounted for 5.5 percent of an estimated $42 billion spent by aged Medicare beneficiaries for health care during 1980, excluding charges for institutional care. Prescription drug use and expenditures were lower among people 65-69 years of age than among people 70-74 or 75-79 years of age. On average, women used more prescriptions and incurred higher charges than did men. Regionally, the average number of prescriptions that were filled per beneficiary was highest in the South and lowest in the West. People who perceived their health status to be poor had approximately four times as many prescriptions filled per person and incurred four times the average annual charge of people who perceived their health status to be excellent. Approximately 68 percent of the total dollars spent by aged Medicare beneficiaries for prescription drugs was paid out-of-pocket, 13.9 percent was paid by private health insurance, and 10.8 percent was paid by Medicaid. The remaining charges were distributed among other payers.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of dental services in 1980.

In this article, we describe the use of dental services by the civilian noninstitutionalized population of the United States in 1980. Data are presented on the extent to which this population is insured for dental expenses, their use of dental services, the charges incurred, and the sources of payment for these services.

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.

Altered lymphocyte reactivity in rheumatoid arthritis.

Blastogenic transformation of peripheral lymphocytes with phytohemagglutinin (PHA), conconavalin A (Con A), and pokeweed mitogen (PWM) was studied in 29 patients with rheumatoid arthritis (RA). The PHA response was depressed in a subgroup of RA patients with erosive disease. The Con A response was also depressed and paralleled the PHA response. The PWM response was not depressed. These results lend support to the hypothesis of a functional defect of cellular immunity in RA. It was shown that lymphocyte responsiveness to a single mitogen concentration is not an adequate assessment of the overall responsiveness of the lymphocytes tested.