Survey-based indices for nursing home quality incentive reimbursement.

Incentive payments are a theoretically appealing complement to nursing home quality assurance systems that rely on regulatory enforcement. However, the practical aspects of incentive program design are not yet well understood. After reviewing the rationale for incentive approaches and recent State and Federal initiatives, the article considers a basic program design issue: creating an index of nursing home quality. It focuses on indices constructed from routine licensure and certification survey results because State initiatives have relied heavily on these readily accessible data. It also suggests a procedure for creating a survey-based index and discusses a sampling of implementation issues.

The economics of safety deregulation: lives and dollars lost due to repeal of motorcycle helmet laws.

Between 1976 and 1980, 28 state legislatures in the United States repealed or weakened their motorcycle helmet-use laws. This paper estimates the number of excess deaths attributable to this deregulatory activity, and the associated economic costs to society. Because of data limitations, no attempt was made to estimate the excess nonfatal injuries and associated costs. We applied a variant of log-linear contingency-table analysis to the monthly counts of motorcycle fatalities in the 48 contiguous states over the period 1975 through 1980. This analysis produced estimates of the total number of deaths, in each of 36 age-sex groups, that could be attributed to changes in the helmet laws. We then estimated the direct and indirect economic costs associated with fatalities in each age-sex group. Our findings indicate that 516 excess deaths occurred in 1980 in the 28 states that weakened or repealed their helmet laws. This represented 24 percent of the total motorcycle fatalities occurring in those states. Women and younger cyclists of both sexes comprised a disproportionate share of excess deaths. The economic costs to society that are associated with the excess fatalities resulting from the repeals of helmet laws total at least $180 million.

Hospital discharge queues in Massachusetts.

There is growing concern over the inappropriate utilization of health care facilities. The high cost of hospital care and the apparent shortage of nursing home beds have focused attention on one aspect of this problem: the clinically unnecessary days (sometimes called "administrative days" or "ADs") spent in hospitals by patients who are awaiting placement in long-term care facilities. In this study, data from a 1976 Massachusetts Department of Public Health survey of patients backed up in hospitals were analyzed to determine the magnitude of the problem and to examine the influence of several major factors that had been hypothesized in previous studies to contribute to the backup. We demonstrate that the average delay of a patient found waiting in a "snapshot" survey (which is often used to estimate the magnitude of the problem) is significantly greater than the average delay experienced by a typical discharged patient. We show that there are at least two major factors that influence the delay time: nursing home preferences in accepting certain types of patients and nursing home occupancy rates in the hospital service area. Neither medical-surgical occupancy rate nor the number of AD patients waiting in the hospital was significantly correlated with the delay time.

Estimating the population median by nomination sampling.

In nomination sampling, the largest values from several independent random samples (nominees) are rank ordered, and an estimate of the population median is formed by interpolating between 2 of these order statistics. The resulting estimate compares favorably to the sample median of a simple random sample from the same population. When historical data sets retain only extreme values, nomination sampling may offer the only practical way to estimate the population median. The approach may also be useful when potential survey respondents will only participate if they can actively influence the selection of cases for analysis.

The distribution of intervals between visits as a basis for assessing and regulating physician services in nursing homes.

We propose a new indicator of responsiveness of physician care in nursing homes: the distribution of intervals between physician visits. Current reimbursement and certification practices work to contain costs and assure minimum quality by influencing the intervals between visits. Data from a comparative study of 2 systems of medical care in nursing homes reveal marked differences in the interval distributions of the 2 systems. The system operating under current reimbursement procedures had interval distributions more concentrated around the minimum reimbursable interval. We interpret this concentration as a sign that the reimbursement procedure makes care less responsive to randomly occurring acute episodes by discouraging brief intervals. The interval distributions also document the impact of Medicaid certification standards on longer intervals. A mathematical model of intervals between visits is developed and used to estimate the interval distribution which would obtain in the absence of current reimbursement and certification procedures. This model also describes the distribution of intervals between physician (and dentist) services to noninstitutionalized individuals. These results suggest that such a model might be used in a system of "stochastic regulation" of physician services which would allow physicians greater freedom to respond to patient needs while still permitting public payors to oversee service provision.

A comparison of patient-centered and case-mix reimbursement for nursing home care.

The trend in payment for nursing home services has been toward making finer distinctions amont patients and the rates at which their care is reimbursed. The ultimate in differentiation is patient-centered reimbursement, whereas each patient's rate is individually determined. This paper introduces a model of overpayment and under-payment for comparing the potential performance of alternative reimbursement schemes. The model is used in comparing the patient-centered approach with case-mix reimbursement, which assigns a single rate to all patients in a nursing home on the basis of the facility's case mix. Roughly speaking, the case-mix approach is preferable whenever the differences between patient's needs are smaller than the errors in needs assessment. Since this condition appears to hold in practice today, case-mix reimbursement seems preferable for the short term.

Nursing home levels of care: problems and alternatives.

Providers and recipients of nursing home care under Medicaid are currently classified into two levels of care to facilitate appropriate placement, care, and reimbursement. The inherent imprecision of the two level system leads to problems of increased cost to Medicaid, lowered quality of care, and inadequate access to care for Medicaid recipients. However, a more refined system is likely to encounter difficulties in carrying out the functions performed by the broad two-level system, including assessment of residents, prescription of needed services, and implementation of service plans. The service type-service intensity classification proposed here can work in combination with a three-part reimbursement rate to encourage more accurate matching of resident needs, services, and Medicaid payment, while avoiding disruption of care.

Nursing home levels of care: reimbursement of resident specific costs.

The companion paper on nursing home levels of care (Bishop, Plough and Willemain, 1980) recommended a "split-rate" approach to nursing home reimbursement that would distinguish between fixed and variable costs. This paper examines three alternative treatments of the variable cost component of the rate: a two-level system similar to the distinction between skilled and intermediate care facilities, an individualized ("patient-centered") system, and a system that assigns a single facility-specific rate that depends on the facility's case-mix ("case-mix reimbursement"). The aim is to better understand the theoretical strengths and weaknesses of these three approaches. The comparison of reimbursement alternatives is framed in terms of minimizing reimbursement error, meaning overpayment and underpayment. We develop a conceptual model of reimbursement error that stresses that the features of the reimbursement scheme are only some of the factors contributing to over- and underpayment. The conceptual model is translated into a computer program for quantitative comparison of the alternatives.

Beyond the GAO Cleveland study: client selection for home care services.

The General Accounting Office (GAO) study of home care services in the Cleveland area is a prominent attempt to inform the selection of clients for these services. This paper critiques two major portions of the GAO study: the "break even" analysis relating level of client impairment to the comparative costs of care in home and institutional settings, and the analysis of risk of institutionalization as a function of client characteristics. Detailed review shows serious flaws in the GAO methodology which undermine the credibility of its estimates of relative service costs and risks of institutionalization. This paper proceeds to place the GAO study within a conceptual framework that permits more systematic consideration of the issue of client selection. Analysis of a model of institutionalization shows that the strategy recommended by GAO of targeting the highest risk individuals may be an inefficient way to use home care resources. Factors pertinent to client selection include not only risk of institutionalization but also level of private support, changes in risk and private support occasioned by an increase in public support, number of clients in the target group, and political attractiveness of the target group.

A new intermediate dental outcome measure: amalgam replacement rate.

The length of time amalgam restorations last before replacement was investigated for use as an intermediate outcome measure in utilization review and quality assurance studies. Based on record data from 37 general dental practices, a determination was made of the average percentage of two- or three-surface amalgams receiving another service at 6, 12, and 24 months from the date of insertion. After 2 years, approximately 13 per cent of the amalgams were replaced, and the estimated median life time for amalgams was between 10 and 14 years. The variation in replacement rates among practices was substantial but was not explained by the technical quality of restorations or several practice characteristics.

A model of prehospital death from ventricular fibrillation following myocardial infarction.

Current efforts to reduce prehospital cardiac mortality focus more on deployment of specially equipped ambulances than on reduction of patient or ambulance delays. To evaluate this strategy, we needed to find a method that would isolate the separate effects of patient delay, ambulance delay, and the resuscitative capability of the ambulance. Using published data, we have generated a mathematical model of death from ventricular fibrillation following myocardial infarction that shows the relationship among these three factors. Analyses based on the model indicate that the potential life saving impact of a defibrillation-equipped ambulance is severely limited due to typical patient response patterns. If the ambulance arrives ten minutes after the onset of infarction, defibrillation capabilities will reduce prehospital mortality from 6 percent to 2 percent. After a more typical delay of 60 minutes, the mortality rises sharply to 13 percent for an unequipped ambulance. With a delay of this length, defibrillation capabilities reduce mortality only to about 12 percent.

Regulatory response to variations in the supply of nursing home beds.

Current regulatory practice seeks to reduce the supply of nursing home beds in areas that rank high in number of beds per capita. The presumption is that a high rank signals "overbedding," i.e., an excess of beds over need. A model of service use is employed to interpret data on the appropriateness of skilled nursing facility (SNF) utilization by Medicaid patients. The analysis reveals that beds per capita is a poor indicator of the relative probability that an area is overbedded, and suggests a more discriminating response to variations in the supply of SNF beds.

A model for certification of need for long-term-care beds.

A model relating bed supply and utilization is presented in the context of the match between need and service, which is controlled by the screening process that allows or denies access to beds. The conventional cost-minimization approach to certification of need, that of seeking to reduce inappropriate use, is contrasted with a service-delivery approach that seeks to promote appropriate use of facilities. The model expresses the quality of the screening process and the sensitivity and specificity of utilization in terms of bed supply, utilization, and need for service, which allows it to be used for needs assessment. The model is applied to data on supply and use of beds in Massachusetts skilled nursing facilities, with screening quality estimated by Monte Carlo methods; the results suggest that need and bed supply are positively associated and that the regional variation in skilled-nursing beds in Massachusetts may reflect real variations in need.

Nursing homes and the Roemer-Feldstein hypothesis.

The theory of certification-of-need is based in large part on the Roemer-Feldstein hypothesis, which holds that demand for services is proportional to bed supply. Athough developed solely from hospital data, this hypothesis is commonly assumed to hold for nursing homes as well. In fact, a high correlation between nursing home bed supply and bed utilization does exist. However, the rate of utilization should not be judged without reference to the appropriateness of use. Analysis of nursing home placement data revealed that overplacement of patients in skilled nursing facilities decreased as bed supply increased. These results suggest that the Roemer-Feldstein hypothesis may provide an inadequate rationale for regulation of nursing home bed supply. Further developments should be based on more sophisticated notions of bed supply, should make reference to the appropriateness of services, and should be subjected to empirical verification.

A miniature accelerometer for detecting glottal waveforms and nasalization.

A lightweight accelerometer has been used to obtain a waveform related to the glottal acoustic output when attached to the neck of a speaker, and to provide an indication of acoustic coupling to the nasal cavities when attached to the external surface of the nose. Examples of signals produced by the accelerometer are shown, and possible clinical applications are discussed.

Patient and bystander response to medical emergencies.

This study of patient and bystander responses to medical emergencies revealed serious shortcomings in the public's ability to respond appropriately to such situations. Decision delays at least as long as ambulance response delays were found to be the result of confusion regarding the seriousness of the emergency, confusion regarding the appropriate reaction to the emergency, and a reluctance to burden the rescue service unnecessarily. A significant group of high-risk patients were identified who not only reacted slowly but who bypassed the emergency ambulance service entirely. A substantial fraction of these patients have had prior contact with the local medical care system for problems related or identical to the one causing the emergency.

Comparison of television and telephone for remote medical consultation.

Television and telephone communications were randomly used to compare their effectiveness in allowing consultation between a hospital-based physician and remote nurse practitioners. Visits using television for consultation averaged 50 minutes as compared with 40 minutes for telephone. This difference was caused by longer work-ups before the consultation, longer delays after it was requested, and longer consultations, themselves, on television. However, television consultations resulted in significantly fewer immediate referrals of patients to hospital physicians: 6 plus or minus 1 as compared to 12 plus or minus 1 per cent (mean plus or minus S.E.M) OF ALL TELEPHONE CONSULTATIONS (P SMALLER THAN 0.005). Although no overall difference in satisfaction was documented between the results of television and telephone consultations, participants preferred the former for medical decision making and cited it for allowing more social interaction than telephone. These findings suggest that television may have its greatest value in remote sites where the sense of isolation is great and the need to reduce long-distance referrals offsets the costs of the system.