Case management for high-cost Medicare beneficiaries.

We estimated the effects of three Health Care Financing Administration (HCFA)-funded case management demonstrations for high-cost Medicare beneficiaries in the fee-for-service (FFS) sector. Participating beneficiaries were randomly assigned to receive case management plus regular Medicare benefits or regular benefits only. None of the demonstrations improved self-care or health or reduced Medicare spending. Despite the lack of effects of these interventions, case management might be cost-effective if it includes greater involvement of physicians, is more well-defined and goal-oriented, and incorporates financial incentives to generate savings in Medicare costs. Models incorporating these changes should be investigated before abandoning Medicare case management interventions.

Differentiated levels of nursing work force demand.

In addition to reviewing the literature about the extent to which basic nursing education is related to actual nursing practice, this article investigates the extent to which the relationship between nursing practice, education, and experience varies across specific health care settings. The literature presented no consistent or systematic association between type and amount of previous nursing experience and current nursing practice. However, the literature generally provided evidence of a consistent and systematic association between baccalaureate preparation and level of registered nurse (RN) practice. The review of practice and organizational differences across the hospital, nursing home, and ambulatory care sectors suggests that baccalaureate-prepared RNs in hospitals may have a more strongly differentiated role relative to those in nursing homes and ambulatory settings. If baccalaureate-prepared nurses continue to be perceived as capable of more complex and independent practice, and if employers believe that they can increase revenues by increasing the quality of nursing care or can save money by shifting to RNs some responsibilities now held by more costly personnel (such as physicians), then demand for baccalaureate-prepared nurses may increase.

Do preset per visit payment rates affect home health agency behavior?

This article reports on preliminary impacts during the first year of a demonstration in which home health agencies (HHAs) were paid a prospectively set rate for each Medicare home health visit rendered, rather than being reimbursed for costs. Forty-seven agencies in five States participated. The evaluation compared the experiences of randomly assigned treatment agencies and their patients with those of control agencies and their patients and found no compelling evidence of any demonstration impact on agency cost per visit, the volume of home health services, agency revenue and profit, patient selection and retention, quality of care, or use and cost of Medicare services.

Medicaid costs and birth outcomes: the effects of prenatal WIC participation and the use of prenatal care.

This study examines the effects of prenatal WIC participation and the use of prenatal care on Medicaid costs and birth outcomes in five states--Florida, Minnesota, North Carolina, South Carolina, and Texas. The study period is 1987 for Florida, Minnesota, North Carolina, and South Carolina and January-June 1988 for Texas. Prenatal WIC participation was associated with substantial savings in Medicaid costs during the first 60 days after birth, with estimates ranging from $277 in Minnesota to $598 in North Carolina. For every dollar spent on the prenatal WIC program, the associated savings in Medicaid costs during the first 60 days ranged from $1.77 to $3.13 across the five states. Receiving inadequate levels of prenatal care was associated with increases in Medicaid costs ranging from $210 in Florida to $1,184 in Minnesota. Prenatal WIC participation was associated with higher newborn birthweight, while receiving inadequate prenatal care was associated with lower birthweight.

It is time to move from health maintenance to health promotion.

The American health care delivery system has traditionally emphasized the treatment of illness instead of the promotion of wellness. Traditional Health Maintenance Organizations (HMOs) have attempted to reduce costs by controlling utilization, discounting and/or sharing risk with providers rather than promoting wellness and prevention. These efforts have, for the most part, been unsuccessful and health care costs and HMO premiums continue to rise. The authors propose it is time for a change and we must look again at what wellness programs can accomplish. It is time to move from an ineffective "health maintenance" approach towards one of "health achievement." Models for the proposed change already exist in the business community where companies have successfully used wellness programs as a tool to decrease health benefits expenditures. The changes proposed must be addressed on multiple levels. Perceptions, attitudes and approaches must be changed. The benefits of wellness must be individually marketed to target groups: blue and white collar workers, business executives and professionals, home makers, preschool and school age children, the elderly and the unemployable.

The evaluation of the National Long Term Care Demonstration. 7. The effect of channeling on the use of nursing homes, hospitals, and other medical services.

An analysis of the impacts of channeling on the use of hospital, nursing home, and other medical services is described. Comprehensive data on hospital and nursing home use were obtained from Medicare and Medicaid claims and provider records; other medical service use was limited to that which is reimbursed by Medicare or Medicaid. The analysis showed that the population served was not at high risk of institutionalization, and that the reductions in nursing home use among the treatment group were neither large nor, generally, statistically significant. An exception was for the small group of persons who were in a nursing home at enrollment, for whom large reductions in nursing home use were found. The population showed a very high use of hospitals and other medical services, but the channeling program had no impact on the use of these services.

The evaluation of the National Long Term Care Demonstration. 9. The effect of channeling on mortality, functioning, and well-being.

A key component of the channeling evaluation was its focus on the life quality of program clients and their caregivers. In this article, life quality results in the areas of mortality, functioning, and client and caregiver well-being are presented for research treatment and control group members. Results show no significant differences in mortality, some beneficial program effects on client and caregiver well-being, and somewhat mixed effects on client functioning.