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Biomedical subjects

J R Lave

Publications and source records attributed to J R Lave.

At least 19 recordsLinked to original sources
PubMed1992

Comparison of recruitment strategies and associated disease prevalence for health promotion in rural elderly.

BACKGROUND: Although interest in health promotion for the elderly is increasing, the issues of recruitment into such programs and self-selection have not been well explored. While clinical studies require high participation levels and expensive recruitment, community efforts are satisfied with recruiting small numbers of volunteers from poorly defined populations. These small samples may not be representative of the populations at risk. METHODS: As part of the Rural Health Promotion Project, a Medicare demonstration, community-based recruitment methods were evaluated and participant characteristics were compared. A total of 3,884 individuals ages 65-79 were recruited in northwestern Pennsylvania, using four sequential recruitment strategies, varying in aggressiveness. The methods were: (A) mail only, (B) mail with phone recruitment follow-up, (C) mail with phone recruitment and scheduling, and (D) mail with aggressive phone recruitment and scheduling. RESULTS: Recruitment yields were Method A, 13.5%; B, 21.1%; and C, 31.6%. The most aggressive Method (D) yielded 37.0% participation. More aggressive methods (C and D) recruited more educated individuals. No other demographic or health status differences were noted. CONCLUSION: These data show that large numbers of the elderly can be recruited into a health promotion program using aggressive methods and professional interviewers.

Aged↗
PubMed1992

A method for assessing the impact of a computer-based decision support system on health care outcomes.

The wide variation in utilization of diagnostic resources has not been decreased by the proliferation of new diagnostic technologies. We wish to test the hypothesis that the introduction of a medical decision support system into clinical practice could potentially lead to more efficient use of diagnostic information, and therefore lead to a reduction in overall laboratory use and cost of care. We have devised and are currently implementing a randomized controlled trial of a computer based decision support system, the University of Pittsburgh version of Quick Medical Reference (QMR). The main purpose of the study is to determine the effect of the QMR program on specific outcome measures: length of hospital stay, number and types of diagnostic tests ordered, and overall charges. An important part of this evaluation is relating the initial level of diagnostic uncertainty expressed by the admitting housestaff team to utilization of diagnostic resources. The purpose of this paper is to describe the methodology for carrying out this controlled trial, and to describe our initial experiences with its implementation.

Decision Support Techniques↗
PubMed1990

Effect of the structure of hospital payment on length of stay.

In response to rapidly rising costs, payers for health care services have made a number of changes in the way they reimburse hospitals for care. In this article we study the effect of different payment methods on the length of stay of Medicaid patients. We examine supply response by type of patient (medical, surgical, and psychiatric) and hospital ownership. We find that per case payment systems and negotiated contracts lead to significant decreases in the length of stay for all groups. Prospective per diem with limits in most cases leads to decreases in the length of stay. In general, we find that the supply response is stronger for psychiatric patients than for medical and surgical patients, and that publicly owned hospitals are more responsive to payment system incentives than are nonpublic hospitals.

Cost Control↗
PubMed1988

Psychiatry under prospective payment: experience in the first year.

The authors present data on changes in resource use by Medicare psychiatric patients in general hospitals after the introduction of the prospective payment system in 1984. Length of stay and charges per discharge during fiscal year 1984 fell 13.8% and 15.9%, respectively, after the new system began, even though 31.8% of the discharges for Medicare psychiatric cases were from exempt psychiatric units. The decrease in length of stay was considerably larger (23.2%) in hospitals with no psychiatric units, which were not exempt from prospective payment.

Fees and Charges↗
PubMed1988

The early effects of Medicare's prospective payment system on psychiatry.

In this paper, we study the effects on psychiatry of Medicare's prospective payment system (PPS) during 1984, as PPS was implemented. We examined data on psychiatric discharges before and after PPS from three kinds of hospitals--those with psychiatric units exempt from PPS, those with nonexempt units, and those that treated psychiatric patients in scatter beds--as well as data on all hospital discharges. We conclude that the providers of psychiatric services responded to the incentives inherent in PPS much the way hospitals as a whole did--with significantly reduced lengths of stay. Of the three kinds of hospitals that rendered psychiatric care, those that treated patients in scatter beds had the greatest reduction in length of stay. Using readmission rates as a gross indicator of quality, we conclude that quality did not suffer because of the shortened stays.

Data Collection↗
PubMed1986

Per case prospective payment for psychiatric inpatients: an assessment and alternatives.

Psychiatric hospitals and clinics are exempted from the Medicare prospective payment system. In this paper we examine the appropriateness of the DRG classification system for psychiatric patients and argue that, using this system as the basis of payment, two types of problems are likely to arise. We categorize these problems as "risks to hospitals" and "risks to patients" and examine the existing literature to determine whether these risks are likely to be significant. We propose a different approach to paying prospectively for psychiatric care, and suggest modifications that could be made to the structure of PPS to mitigate negative incentives embedded in the current system. Although the main focus of the paper is on the unit of payment, we also make some observations about issues arising in connection with the level of payment.

Commitment of Persons with Psychiatric Disorders↗
PubMed1986

Financing graduate medical education using multiple regression to set payment rates.

There has been considerable public policy debate concerning the appropriate rate of adjustment to the Medicare prospective payment system for the indirect costs of graduate medical education. The model that we present in this paper represents one of the first times that the statistical technique of multiple regression has been used to establish payment rates for hospitals. We also review the alternative specifications of the model and conclude that factors other than educational programs are responsible for most of the higher costs in teaching hospitals. We conclude by making recommendations for reforming the Medicare prospective payment system.

Costs and Cost Analysis↗
PubMed1985

The psychiatric DRGs. Are they different?

The relative homogeneity of medical, surgical, and psychiatric diagnosis-related groups (DRGs) are examined. Using data from the State of Maryland and the Health Care Financing Administration we studied the amount of variation in resource utilization within the DRGs. The estimated coefficients of variation of resource utilization for the surgical DRGs were found to be significantly smaller than those estimated for both medical and psychiatric DRGs. The authors were unable to reject the hypothesis that the coefficients of variation for medical and psychiatric DRGs were different. These results suggest that hospitals are at substantial but equal risk under a DRG-based payment system for both medical and psychiatric DRGs.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

The impact of Medicaid benefit design on length of hospital stay and patient transfers.

The authors examined how the Medicaid hospital benefit structure affects the length of stay of psychiatric inpatients and transfers to state mental hospitals and nursing homes. They hypothesized that length-of-stay and discharge patterns would depend on five classes of variables: patient characteristics, diagnosis, mental health status, hospital characteristics, and benefit structure. Analysis of 976 Medicaid cases showed that the variables together accounted for only 17 percent of the variation in patient length of stay; benefit structure alone accounted for 6 percent of the variation, slightly less than the diagnostic variables. A patient's clinical status was the most important predictor of transfer to state mental hospitals, although benefit structure had a significant effect. It had no effect on patient transfers to nursing homes. The authors discuss the implications of the findings for designing prospective payment systems for psychiatric patients under Medicare.

Hospitals, State↗
PubMed1985

Cost containment policies in long-term care.

The rapidly increasing growth of the elderly population in the United States, especially the increasing proportion of the "old old" among the elderly, has thrust long-term care--its evolution, organization, and financing--into the national limelight. In this report of the effectiveness of various policies to contain the costs of long-term care, I focus on the aggregate public costs of providing this care. I also discuss the impact of public policy on access to needed services by the vulnerable population, the quality of these services, and the quality of life of the recipients of long-term care.

Aged↗
PubMed1985

Is compression occurring in DRG prices?

Many analysts believe that the prices of truly high cost DRGs are set low relative to their actual costs whereas the prices of truly low cost DRGs are set high relative to their costs. To test whether such "compression" is occurring, I examined the algorithm that the Health Care Financing Administration used to create its DRG pricing structure. I then compared the HCFA algorithm with the more refined weighting systems used by Maryland and New Jersey to create their DRG payment systems. I found that compression is indeed occurring in the Medicare system relative to both the New Jersey and the Maryland systems. This compression will assume special urgency for some hospitals when the standardized national DRG payment system is phased in or if stringent limits are placed on the overall rate of increase in DRGs.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1979

Characteristics of individuals who identify a regular source of medical care.

Having a source where medical services are regularly received is an antecedent to securing high quality medical care; it facilitates access and indicates that the individual is not alienated from the health care delivery system. In this paper we develop models to characterize individuals, both children and adults, who claim a regular source of care. The models are estimated using a logit analysis (since the dependent variable is 0-1) applied to survey data on residents of East Palo Alto, California. These data indicate that in this low-income, predominately black population the most important factor influencing whether a child will have a regular source of medical care is whether the parents have a regular source. For adults, the anticipated need for care (as measured by health status), time in community, and sex were all found to be important. The type of individual least likely to have a regular source of care is a low-income, unmarried male who is in good health and is a recent arrival to the community. The individuals most likely to need easy access to medical care and continuity of care are most likely to have a regular source of care, and vice versa.

Adult↗