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Biomedical subjects

J Cromwell

Publications and source records attributed to J Cromwell.

At least 55 records · Page 3Linked to original sources
PubMed1987

Packaging physician services: alternative approaches to Medicare Part B reimbursement.

More than a quarter of the rapid growth in physician expenditures since the advent of the Medicare program can be ascribed to greater service intensity, generally through unpackaging of physician services, procedure inflation, and the involvement of multiple physicians. One way to achieve effective cost control is to restrain prices and the number of services simultaneously through redefining the payment unit from a narrow procedure to a comprehensive package of services. In this paper, we explore five means of packaging physician services: collapsed procedure, office visit, special procedure, ambulatory condition, and inpatient condition packages. While three packages hold promise for reining in the costs of physician services in the Medicare program, two raise important policy considerations that would have to be addressed before they could be given further consideration.

Ambulatory Care↗
PubMed1987

Variations in hospital malpractice costs, 1983-1985.

The rapid increase in the costs of hospital liability in recent years has focused attention on the present and future ability of hospitals to offer complex, high-risk procedures. In this study of the costs of malpractice coverage and their rates of increase between 1983 and 1985, we found that the rapid increases in the costs of liability insurance are largely accounted for by the fact that hospitals are purchasing more coverage. Their costs per dollar coverage remained constant over the two-year period. Although malpractice cost differences are narrowing among the nine U.S. census regions, our analyses suggest that there will be significant inequities in what Medicare allows in its prospective payment formula for malpractice insurance costs.

Costs and Cost Analysis↗
PubMed1987

Sources of hospital cost variation by urban-rural location.

Under current law, Medicare's Prospective Payment System (PPS) recognizes a 25% differential in standardized average costs per admission between rural and urban areas. Using Medicare Part A and B claims data from four states across the country, this paper employs descriptive and multivariate techniques to explain the underlying sources of cost variation. DRG mix and within-DRG severity differences were found to contribute only 10-15% to the overall urban-rural variation compared to about one third for wage differences. Differences in procedure intensity for basically similar patients explained another 25-50% of the urban-rural difference depending on illness. Evidence was also found for systematic cost and procedure differences between core city versus suburban hospitals. If the urban-rural rate differential were eliminated, the impact on urban hospitals could have major effects on the intensive way in which physicians treat patients. Whether this would have demonstrable outcome effects is unknown, but initial severity differences alone do not justify the observed procedural differences.

Aged↗
PubMed1986

Physician-induced demand for surgery.

Following up the earlier findings by Fuchs on surgeon-induced demand, this paper makes numerous data and econometric improvements in conducting a test of neoclassical and inducement theories. A simultaneous equation model is used to estimate physician demand and equilibrium fees for surgery from a sample of 350 PSUs over the 1969-76 period. The results provide definite support for the notion of competitive market failure--particularly in large metropolitan areas. Other things equal, fees and utilization are higher in surgeon-rich areas although our estimated shift elasticities were only about one-third those found by Fuchs. A statistically significant, albeit small price elasticity of demand for surgery was also obtained, in contrast to Fuchs. Increasing monopoly and disequilibrium models are also tested without altering the basic findings. Where surgeons were in short supply, their availability significantly affected surgery rates, although a small supply effect was found in plentiful areas as well.

Costs and Cost Analysis↗
PubMed1986

A profile of emergency physicians 1984-1985: demographic characteristics, practice patterns, and income.

Emergency physicians (EPs) were profiled using data from a recent national survey of physicians. In addition, we compared EPs to other physicians on demographic and practice characteristics. EPs were younger than physicians in other specialties and were less likely to be foreign medical graduates or board certified. EPs were far more likely to be employed by hospitals and on salary. Their net income averaged $93,000 in 1983, although hospital employees had lower average incomes ($83,000) than did those employed by a corporation or self-employed in a group practice ($101,000). Compared to other specialties, their average income was higher than nonsurgeons, but still far below surgeons. While EPs and other physicians spent about 50 to 51 hours per week in medical activities, EPs saw more patients per hour. EPs saw more uninsured individuals. These results have implications for patient access, "entrepreneurism" in the specialty, and credentialing.

Adult↗
PubMed1986

Medicaid myths: trends in Medicaid expenditures and the prospects for reform.

Medicaid expenditures, which had reached more than +32 billion by 1981, have grown substantially throughout the program's history. As a result, the conventional wisdom is that Medicaid expenditures represent a significant public-policy problem. Using other measures, however, it can be shown that the program is much less of a problem than it appears to be. By 1981, spending for Medicaid represented only 12.7 percent of total state spending and had contributed only 14.2 percent to the overall growth in state expenditures since 1965. Moreover, considering only the funds which states raise from in-state sources, the median share of state budgets accounted for by Medicaid was just 5.6 percent, and only 7 states spent as much as 9 percent of their own money on the program. These figures suggest that the marginal reductions in Medicaid expenditures which would result from typical program changes are likely to be so small that rational state officials might be unwilling to incur the political opposition of powerful provider groups or the resistance of large state bureaucracies by proposing substantial reforms. The major exceptions are the few states with very large programs where even small proportional savings would amount to millions of dollars. We conclude that, given its present federal-state form and the current distribution of expenditures, it is unlikely that major reforms will be enacted because the stakes are too small for most states and the federal interest is too diffused.

Health Expenditures↗
PubMed1985

Relative incomes and rates of return for U.S. physicians.

Since 1967 the supply of physicians in the U.S. has been growing by more than 3 percent per annum. This, coupled with public insurer fee discounts, might have been expected to depress both the relative and absolute incomes of physicians in spite of growing insurance coverage and new technologies. Real incomes of physicians did decline at a 0.2 percent annual rate between 1967 and 1980, but this was apparently due to economy-wide events since the income trends for lawyers, dentists, and college graduates were virtually identical. Internal rates of return to undergraduate medical training remained high--between 14 and 17 percent in 1980. Specialty training became more profitable for internists, general surgeons, and obstetricians/gynecologists (all with 10-15 percent rates of return), while pediatricians continued to suffer a financial loss. While Medicare and Medicaid fee discounts have been criticized as inequitable, the programs are also shown to provide a 'hidden subsidy' to physicians during residency training, materially adding to rates of returns.

Data Collection↗
PubMed1985

Physician losses from Medicare and Medicaid discounts: how real are they?

Physicians' claims that extensive Medicare and Medicaid fee discounting imposes an inequitable burden on them are examined using survey data from the Health Care Financing Administration on 5,000 primary care physicians. A definite fee hierarchy is documented, with the physician's usual charge at the top and Medicare and Medicaid allowables at the bottom. Under usual, customary, and reasonable methods, physicians can use fees to maximize payment, and insurer attempts to control fees result in both sides participating in a revenue maximization-expenditure control game. Raising Medicare and Medicaid allowables to the physician's usual fee is shown to result in large windfall gains that are unnecessary and unjustified in terms of work effort, human capital investment, or eliciting an adequate supply of practitioners.

Blue Cross Blue Shield Insurance Plans↗
PubMed1985

Medicare expenditures and utilization under State hospital rate setting.

In this study we analyzed the National Hospital Rate-Setting Study findings concerning the effects of State prospective reimbursement (PR) programs on Medicare expenditures and utilization; we used Medicare beneficiary-based data complied from a sample of approximately 1,300 counties in States with and without rate-setting programs for the 5-year period 1974-78. The statistical evidence suggests that stringent PR programs have not resulted in hospitals using Medicare to cross-subsidize losses elsewhere. In addition, it appears that Medicare has been a passive recipient of the same kinds of regulatory benefits accruing to PR-covered patients (i.e., costs and intensity of care have been constrained).

Economics, Hospital↗
PubMed1984

An economic model of large Medicaid practices.

Public attention given to Medicaid "mills" prompted this more general investigation of the origins of large Medicaid practices. A dual market demand model is proposed showing how Medicaid competes with private insurers for scarce physician time. Various program parameters--fee schedules, coverage, collection costs--are analyzed along with physician preferences, specialties, and other supply-side characteristics. Maximum likelihood techniques are used to test the model. The principal finding is that in raising Medicaid fees, as many physicians opt into the program as expand their Medicaid caseloads to exceptional levels, leaving the maldistribution of patients unaffected while notably improving access. Still, the fact that Medicaid fees are lower than those of private insurers does lead to reduced access to more qualified practitioners. Where anti-Medicaid sentiment is stronger, access is also reduced and large Medicaid practices more likely to flourish.

Fee Schedules↗
PubMed1983

Impact of an all-or-nothing assignment requirement under Medicare.

In an effort to raise assignment rates, some policymakers have considered dropping Medicare's case-by-case assignment option. Physicians would have to decide whether to accept all of their patients on assignment, or none of them. In a 1976 national survey, over two-thirds of the physicians stated they would take none of their patients on assignment if forced to choose. Simulation analysis showed that in that event, assignment rates nationwide would fall almost 10 percent. The mean supply of assigned visits would actually increase 11 percent for general practitioners, while decreasing 12-25 percent for general surgeons, internists, and obstetricians/gynecologists.

Decision Making↗
PubMed1982

Physician behavior under the Medicare assignment option.

Using a national sample of general practitioners, internists, and general surgeons, we analyzed the willingness of physicians to accept Medicare patients on assignment. Assignment rates were found to be very sensitive to reimbursement and administrative practices under Medicare. A ten percent increase in the prevailing charge, for example, raised assignment by 14.7 percent. The assigned and non-assigned components of the Medicare program were found to compete with each other; assignment rates were lower where the demand for non-assigned services was stronger. As for the kinds of physicians who take assignment, they were disproportionately general surgeons and foreign medical graduates.

Aged↗
PubMed1982

Medicaid participation by psychiatrists in private practice.

Using national survey data, the authors examined the characteristics of psychiatrists in private practice who treat Medicaid patients. They found that the average Medicaid participation rate was 8%; 39.9% of psychiatrists did not see any Medicaid patients. Participating psychiatrists were more likely to be foreign medical graduates and to have a hospital-oriented practice. Psychiatrists with large Medicaid practices saw significantly more patients per week but spent less time with them. These psychiatrists were also disproportionately located in the West. The authors conclude that these variations are a result of state program differences in Medicaid reimbursement and eligibility policies.

Appointments and Schedules↗
PubMed1982

The effects of prospective reimbursement programs on hospital adoption and service sharing.

A previous article in this journal (Coelen and Sullivan, 1981) reported new evidence that many State hospital prospective reimbursement (PR) programs have been successful in reducing hospital cost inflation. Limiting proliferation of redundant technologies and community services may be one method of reducing this cost inflation. Data compiled from a sample of over 2,500 hospitals in 15 rate-setting and other States between 1969 and 1978 were used to determine PR's effect on both service adoption and sharing. Evidence indicates a consistent, retarding effect on all services for New York, the country's oldest, most stringent program. Several other States, notably Minnesota, Maryland, New Jersey, Washington, and Wisconsin showed retarding effects on costly rapidly diffusing services such as open heart surgery, intensive care units (ICUs), and social work, as well as accelerating the phasing-out of redundant services, such as the premature nursery. We found no consistent, significant effects on service sharing.

Data Collection↗