Designing the national resident assessment instrument for nursing homes.

In response to the Omnibus Reconciliation Act of 1987 mandate for the development of a national resident assessment system for nursing facilities, a consortium of professionals developed the first major component of this system, the Minimum Data Set (MDS) for Resident Assessment and Care Screening. A two-state field trial tested the reliability of individual assessment items, the overall performance of the instrument, and the time involved in its application. The trial demonstrated reasonable reliability for 55% of the items and pinpointed redundancy of items and initial design of scales. On the basis of these analyses and clinical input, 40% of the original items were kept, 20% dropped, and 40% altered. The MDS provides a structure and language in which to understand long-term care, design care plans, evaluate quality, and describe the nursing facility population for planning and policy efforts.

Choice of payment plan in the Medicare capitation demonstration.

This article identifies factors that influence the choice between joining an HMO and remaining with the traditional fee-for-service system among aged Medicare beneficiaries in three communities. Sources of marketing information were found to be strongly and positively related to the decision to join the HMO. Among beneficiaries who had to switch providers to join, persons who had a prior usual source of care and those who were satisfied with the amount of paperwork required to use that source of care were less likely to enroll in the HMO. Persons who did not have to switch providers to join the HMO were more likely to enroll in the prepaid program if they were satisfied with the amount of paperwork involved in using the HMO prior to the demonstration. Differences among the three communities suggest that the barrier to HMO enrollment presented by having a prior source of care who is not affiliated with the HMO may attenuate as the number of competing HMOs in the community increases, making the medical care environment more competitive. In the community with the most HMOs, persons who already had supplemental insurance were less likely to enroll than those who did not. None of the six HMOs studied experienced adverse selection, based on pre-enrollment health status.