Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study.

BACKGROUND: Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care. METHODS: We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994-95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care. RESULTS: On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34-38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14-26 percentage points). CONCLUSION: According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.

Trends in funding and use of alcohol and drug abuse treatment at specialty facilities, 1990-1994.

OBJECTIVES: This study examined trends in funding and use of alcohol and drug abuse treatment at specialty facilities between 1990 and 1994. METHODS: The 1990 and 1994 National Drug and Alcohol Treatment Unit Surveys were used to estimate annual funding and number of clients in treatment. RESULTS: Public funding increased by 5%, whereas private funding decreased by 28% in real terms between 1990 and 1994. The number of publicly and privately funded clients decreased slightly. CONCLUSIONS: The rapid growth in private and public sector substance abuse funding during the 1980s has not continued into the 1990's.

Cost savings and physician responses to global bundled payments for Medicare heart bypass surgery.

In 1991 the Health Care Financing Administration (HCFA) began the Medicare Participating Heart Bypass Center Demonstration, in which hospitals and physicians are paid a single negotiated global price for all inpatient care for heart bypass patients. During the first 27 months of the demonstration, the Government and beneficiaries together saved more than $17 million on bypass surgery in four participating institutions. Average total cost per case fell in three of the four hospitals during the 1990-93 period as the alignment of physician and hospital incentives resulted in physicians changing their practice patterns to shorten stays and reduce costs.

Access to care in rural America: impact of hospital closures.

This article employs a quasi-experimental, pre/post comparison group design to determine whether rural hospital closures (n = 11) have had a detrimental impact on access to inpatient and outpatient care for the Medicare population. Closure areas experienced a significant decrease in medical admissions, although admission rates remained higher than in comparison areas. Physician services were not found to substitute for inpatient services following a closure. No adverse impacts on mortality were observed. Patients in closure areas were more likely to be admitted to urban teaching hospitals following the closure of their local hospital.

National and state spending on specialty alcoholism treatment: 1979 and 1989.

The National Drug and Alcohol Treatment Unit Survey was used to measure changes in specialty alcoholism treatment spending between 1979 and 1989 nationally and by state. National spending more than doubled from $1.6 billion to $3.8 billion in 1989 dollars. Private spending increased more rapidly than public spending, although most clients continue to be publicly funded. Dramatic differences across states in public funding growth were partially explained by differential increases in per capita income and in federal substance abuse block grants. Access to treatment continues to vary widely across the states.

State variations in public and private alcoholism treatment at specialty substance abuse treatment facilities.

This article reports characteristics of state specialty alcoholism treatment systems estimated from the 1989 National Drug and Alcohol Treatment Unit Survey (Ndatus). Ndatus is adjusted to correct for item nonresponse and differential unit nonresponse across states. We estimate that $3.8 billion was spent nationally on specialty alcoholism treatment in 1989. Per capita funding ranged from $52 in Alaska to $6 in Mississippi. Clients in treatment per capita and funding per client-day each varied more than 10-fold across states. Comparison of treatment system measures with indicators of the need for alcoholism treatment showed little systematic relationship across states.

Measuring differences and similarities in hospital caseloads: a conceptual and empirical analysis.

OBJECTIVE: This article conceptually and empirically evaluates alternative index measures that have been used to distinguish among hospital caseloads. It introduces two new measures. DATA SOURCES/STUDY SETTING: The study relies on 1987 Medpar data, which provide a 100 percent sample of Medicare Part A claims for the calendar year. STUDY DESIGN: Descriptive statistics indicate the sensitivity of alternative caseload measures to hospital bed size, region, and urban/rural location. Multiple regression analysis then examines the ability of the caseload measures to distinguish among hospitals based on hospital- and area-specific characteristics. DATA COLLECTION/EXTRACTION METHODS: A provider level file containing the number of cases treated by each provider in each DRG was constructed from the Medpar data and merged with data from the American Hospital Association and the Area Resource File. PRINCIPAL FINDINGS: Different indexes purporting to measure hospital specialization are often evaluating very different aspects of the hospitals' caseloads. Prior work has indicated a specialization among hospitals during the period from 1980 to 1985. Replication of this work using other indexes could verify the increase in specialization and might provide a clearer picture of market or hospital characteristics associated with changing caseloads.

An update on physician practice cost shares.

The 1988 physicians' practice costs and income survey (PPCIS) collected detailed costs, revenues, and incomes data for a sample of 3,086 physicians. These data are utilized to update the Health Care Financing Administration (HCFA) cost shares used in calculating the medicare economic index (MEI) and the geographic practice cost index (GPCI). Cost shares were calculated for the national sample, for 16 specialty groupings, for urban and rural areas, and for 9 census divisions. Although statistical tests reveal that cost shares differ across specialties and geographic areas, sensitivity analysis shows that these differences are small enough to have trivial effects in computing the MEI and GPCI. These results may inform policymakers on one aspect of the larger issue of whether physician payments should vary by geographic location or specialty.

Acanthocytosis associated with myelodysplasia.

Dysplastic hematopoiesis associated with erythrocyte macrocytosis is a morphologic hallmark of myelodysplasia. We report the cases of six patients with myelodysplasia in which acanthocytosis was the predominant red blood cell (RBC) abnormality. In each case acanthocytes represented 5% to 10% of circulating RBC forms and was the primary reason for referral in two cases. None of the patients had comorbid conditions known to be associated with acanthocyte formation. Myelodysplasia should be considered in the differential diagnosis of acanthocytosis, particularly in the anemic, elderly individual. Acanthocytosis may be a harbinger of an unrecognized, hematologic stem-cell disorder.