Trends in length of stay for Medicare patients: 1979-87.

Hospital length of stay (LOS) declined steadily during the 1970s, then rapidly during the early years of the Medicare prospective payment system (PPS). In this article, the authors examine trends in hospital LOS for Medicare patients from 1979 through 1987 for all cases combined, for medical and surgical cases separately, and for different geographic regions. The increase in LOS for surgical cases from 1985 through 1987 represented two offsetting trends. Continuing declines in LOS for most procedures were offset by an increased shift toward complex, long LOS procedures.

A study of gastroenterologists in the United States.

A two-part study of gastroenterologists (GEs) was conducted. One component was the analysis of 1987 Part B Medicare Annual Data to assess volume of services and patterns of reimbursement to gastroenterologists. This study demonstrated that two-thirds of services billed by GEs are medical visits, whereas two-thirds of GEs' income is derived from endoscopies. Five endoscopies account for 50% of GEs' allowed charges. Correcting for case-mix and geographic location, GEs' charges for endoscopies are still 10% higher than other physicians performing the same procedures. The second component of the study was a survey of 379 members of three major gastroenterological associations. Demographic and practice characteristics are reported and compared, when possible, with other physician specialties. Respondents estimated they spent 52 h/wk in inpatient and outpatient activities, of which 17.5 h were spent performing endoscopies. Fewer than 50% of respondents billed for 31.4 h of professional activity each week. Medicare patients comprise 38.2% of their patients. Most physicians did not balance-bill, or balance-billed Medicare patients only when they were able to pay. Malpractice premiums have risen from $6,511 to $9,540 during the past 3 yr. Over 95% of respondents were able to correctly identify those conditions requiring upper gastrointestinal (UGI) endoscopy and colonoscopy.

Predicting hospital accounting costs.

Two alternative methods to Medicare Cost Reports that provide information about hospital costs more promptly but less accurately are investigated. Both employ utilization data from current-year bills. The first attaches costs to utilization data using cost-charge ratios from the previous year's cost report; the second uses charges from current year's bills. The first method is the more accurate of the two, but even using it, only 40% of hospitals had predicted costs within plus or minus 5% of actual costs. The feasibility and cost of obtaining cost reports from a small, fast-track sample of hospitals should be investigated.

Assessing cost effects of nursing-home-based geriatric nurse practitioners.

Employment of geriatric nurse practitioners (GNPs) is one strategy to improve nursing home care. The effects of GNPs on costs and profitability of nursing homes and on costs of patient medical service use outside the nursing home are examined. Employment of GNPs does not adversely affect nursing home costs or significantly affect profits. There is some evidence of cost savings in medical service use for newly admitted patients but no evidence of savings for continuing residents. GNPs reduce the use of hospital services for both groups, and the reduction is statistically significant for newly admitted patients.

Predicting hospital accounting costs.

Two alternative methods to Medicare Cost Reports that provide information about hospital costs more promptly but less accurately are investigated. Both employ utilization data from current-year bills. The first attaches costs to utilization data using cost-charge ratios from the previous year's cost report; the second uses charges from current year's bills. The first method is the more accurate of the two, but even using it, only 40 percent of hospitals had predicted costs within plus or minus 5 percent of actual costs. The feasibility and cost of obtaining cost reports from a small, fast-track sample of hospitals should be investigated.

Child care for preschoolers: differences by child's age.

Because of the high rates of employment of mothers, a large and increasing number of preschool children receive regular care from someone else. This article develops and tests hypotheses about the choice of child care arrangements for younger and older preschool children, using data from the National Longitudinal Survey of Young Women. We argue that appropriate care depends on the age of the child. It includes care by the mother or a paid provider in the child's home for children aged 0-2 and mother care and nursery school or center care for those 3-5. We estimate models of the mother's employment and choice of child care separately for younger and older preschoolers. Our results show that need for care, presence of substitutes for the mother, financial resources, and preferences all affect both full-time care by the mother and the type of child care chosen by working women, although they affect these two decisions in different ways.

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.

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.