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Biomedical subjects

R E Schlenker

Publications and source records attributed to R E Schlenker.

17 recordsLinked to original sources
PubMed1997

Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings.

OBJECTIVE: To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. DESIGN: Inception cohort stratified by provider type and followed prospectively for 6 months. SETTING: A total of 92 hospital-based units and freestanding facilities from 17 states. PATIENTS: A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994. MAIN OUTCOME MEASURES: At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments. RESULTS: On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients. CONCLUSIONS: Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.

Activities of Daily Living↗
PubMed1995

Patient-level cost of home health care under capitated and fee-for-service payment.

This article examines costs for a national sample of 1,260 Medicare patients receiving home health care from 38 home health agencies. It uses data from a study that compares home health care provided to Medicare beneficiaries in health maintenance organizations (HMOs) and the traditional fee-for-service (FFS) system. The major findings indicate significantly lower costs, based on fewer home health visits, for HMO patients compared to FFS patients, even after adjustment for case mix and other factors. However, FFS patients also attain better outcomes, suggesting that HMOs may provide too few visits to home health patients. At the same time, the number of visits to FFS patients may be greater than is necessary to achieve the better FFS outcomes.

Aged↗
PubMed1995

Case mix of home health patients under capitated and fee-for-service payment.

OBJECTIVE: We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN: A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS: Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA: Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES: The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS: (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS: The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences.

Activities of Daily Living↗
PubMed1991

Administrative and policy issues in reimbursement for nursing home capital investment.

The way in which states reimburse for nursing home capital costs can create incentives for nursing home owners to use the home primarily as a vehicle for real estate speculation, with potentially adverse consequences for patient care. In order to help promote and control the stability, adequacy, and quality of capital investment in long-term care, an increasing number of states are using a fair-rental approach for calculating capital reimbursement. In this article we compare the fair-rental approach with traditional cost-based capital reimbursement in terms of administration and policy. We discuss issues of concern to the state (cost and reimbursement design options) and the investor (after-tax cash flows, rate of return, etc.). Our analysis suggests that fair-rental systems may be superior to traditional cost-based reimbursement in promoting and controlling industry stability, while at the same time providing an adequate return to investors, without incurring long-term increases in the costs of administering programs.

Capital Expenditures↗
PubMed1991

Nursing home costs, Medicaid rates, and profits under alternative Medicaid payment systems.

This analysis compares nursing home costs, Medicaid payment rates, and profits under three Medicaid nursing home payment systems: case-mix, facility-specific, and class-rate systems. Data used were collected from 135 nursing homes in seven states. The association of case mix with costs, rates, and profits under the three payment systems was of particular interest. Case mix was more strongly associated (positively) with patient care cost and the Medicaid rate for the case-mix systems than for the other systems, particularly the class-rate systems. In contrast, case mix and profits were not associated in the case-mix or facility-specific systems, but were negatively associated in the class rate systems. Overall, the results suggest that case-mix systems have some important advantages over other payment systems, but further research is needed on larger samples and involving the newer case-mix systems.

Aged↗
PubMed1990

Quality of long-term care in nursing homes and swing-bed hospitals.

By 1989, more than 1,100 hospitals in rural communities throughout the United States were using hospital beds as swing beds to provide both long-term and acute care. In this study, the quality of long-term care in swing-bed hospitals was compared with the quality of nursing home care, using patient outcomes along with both process and structural measures of quality. Several methodological and conceptual points on measuring and analyzing the quality of long-term care are discussed in this article. Data were analyzed on approximately 2,000 patients in four different primary data samples, three of which were longitudinal involving multiple follow-up points. An analysis of changes in patient status over time, hospitalization rates, rates of discharge to independent living, services provided, and certain structural indicators showed that (1) relative to nursing home care, swing-bed care is more effective in enhancing functional outcomes and discharge to independent living and in reducing hospitalization for long-term care patients, and (2) nursing home care appears more desirable than swing-bed care for long-stay, chronic care patients with no rehabilitation potential. Swing-bed hospitals have gravitated largely to admitting postacute long-term care patients. They do not typically compete directly with community nursing homes for chronic care patients. The greater effectiveness of swing-bed care for patients with near-acute long-term care needs suggests that this approach should be considered in urban communities and that we should scrutinize our current tendency to place in traditional nursing homes many patients who have at least some rehabilitation potential.

Activities of Daily Living↗
PubMed1989

Case-mix reimbursement for nursing homes: objectives and achievements.

Six state Medicaid programs currently use case-mix reimbursement (CMR) systems to pay nursing homes. Quality of care is not decreased under these payment systems and may actually have increased in some instances, while access for heavy-care Medicaid patients appears to have improved. As for equity of payment, CMR methods when compared with others tend to redistribute funds more in accord with resident care needs. Not all of the six states have made cost containment an explicit objective, and program administration costs typically increase. Since CMR systems primarily affect relative payments, however, they can be shaped to achieve total program expenditure objectives.

Cost Control↗
PubMed1989

Swing-bed hospital cost and reimbursement.

Small rural hospitals can provide long-term care in acute care beds as part of the National Swing-Bed Program enacted in 1980. Medicare reimbursement for swing-bed care is based on the incremental cost concept. This article estimates the incremental cost to hospitals of swing-bed care and assesses the adequacy of swing-bed reimbursement in light of those estimates. Other swing-bed reimbursement policy issues are discussed, including payment for ancillary services, potential bundling of routine and ancillary reimbursement, and the possible incorporation of case mix into swing-bed payment determination.

Ancillary Services, Hospital↗
PubMed1986

Medicaid and non-Medicaid case mix differences in Colorado nursing homes.

Profiles of case mix and related variables were compared for 1,064 Medicaid and 459 non-Medicaid residents of 65 freestanding nursing homes in Colorado in 1980. The results point to substantial case-mix differences, with Medicaid residents typically characterized by fewer and less intense long-term care problems as well as greater independence in functioning (ADLs). Policy impacts of these findings in Colorado have included a legislatively mandated home and community-based care program as well as a more stringent preadmission certification program for Medicaid clients. The method of comparing Medicaid and non-Medicaid case mix in nursing homes appears to have policy relevance for other states as well. Research implications in the areas of measuring severity of long-term care problems and measuring residents' functional abilities apart from services received are also suggested.

Activities of Daily Living↗
PubMed1986

Case mix reimbursement for nursing homes.

Nursing home care is growing in importance as the population ages and as Medicare's prospective payment system encourages earlier discharges from acute care settings to nursing homes. Nursing home reimbursement policy is primarily a Medicaid issue, since Medicaid pays for about half the nation's nursing home care. The research reviewed in this article suggests a strong association between case mix and cost, and a weaker but still positive association between quality and cost. The research also implies that traditional nursing home reimbursement methodologies may impede access and may lower quality for Medicaid (and Medicare) recipients. To offset these problems, several states have recently begun to incorporate case mix directly into the reimbursement process. These systems deserve careful policy consideration.

Costs and Cost Analysis↗
PubMed1986

Hospital swing-bed care in the United States.

As a result of federal legislation implemented in 1982, hospital beds that are used to provide both long-term care and acute care are now proliferating rapidly throughout the country. Termed swing beds, such beds are currently restricted to rural areas. However, due largely to the impacts of Medicare DRG reimbursement, pressure is mounting to expand the swing-bed approach to urban settings. Swing beds appear to fill a significant gap between the relatively intense medical needs of post-acute care patients (now discharged earlier) and the capacity of our current nursing home delivery system to meet such needs. The evolution of swing beds is marked by an unusual blend of experimentation, scientific investigation, and public policy response to community and personal health care needs. This article summarizes that evolution, highlighting research findings and key policy developments. It concludes with the current status of the national swing-bed program and issues pertinent to future directions.

Bed Conversion↗
PubMed1985

Nursing home case-mix differences between Medicare and non-Medicare and between hospital-based and freestanding patients.

Case-mix differences between Medicare and non-Medicare nursing home patients and between hospital-based and freestanding nursing home patients were assessed for a sample of 756 patients from 26 nursing homes in six states in 1983. Significant differences were found between Medicare and non-Medicare patients and between hospital-based and freestanding nursing home patients. Thus, two attributes, the percentage of Medicare patient days and whether a nursing home is hospital-based or freestanding, probably should be taken into consideration as facility-level case-mix indicators in determining Medicare reimbursement until a more refined approach to case-mix reimbursement can be developed. Hospital-based/freestanding case-mix differences also suggest that Medicaid reimbursement should recognize potential differences in cost structure between these two types of facilities.

Activities of Daily Living↗
PubMed1985

Estimating patient-level nursing home costs.

This article presents a methodology developed to estimate patient-level nursing home costs. Such estimates are difficult to obtain because most cost data for nursing homes are available from Medicare or Medicaid cost reports, which provide only average values per patient-day across all patients (or all of a particular payer's patients). The methodology presented in this article yields "resource consumption" (RC) measures of the variable cost of nursing staff care incurred in treating individual nursing home patients. Results from the application of the methodology are presented, using data collected in 1980 on a sample of 961 nursing home patients in 74 Colorado nursing homes. This type of approach could be used to link nursing home payments to the care needs of individual patients, thus improving the overall equity of the payment system and possibly reducing the access barriers facing especially Medicaid patients with high-cost care needs.

Colorado↗
PubMed1983

The private sector and competition in health care markets.

This paper reviews the historical trends in the regulatory and competitive approaches to containment of health care costs, covering efforts in both public and private sectors. The current interest in the potential of private-sector initiatives to stimulate competition in health care insurance and provider markets is highlighted. Since neither the workings of competition in health care nor the role and impact of the private sector in stimulating such competition are well understood, the concluding section discusses important research issues surrounding these topics.

Cost Control↗
PubMed1980

The future health care organization.

A major task facing hospital administrators today is to prepare their institutions to take on substantial new responsibilities and roles in the future. Management initiative is the key ingredient.

Aged↗
PubMed1975

HMOs, competition, and government.

This article considers the role of three sets of forces affecting the development of health maintenance organizations (HMOs) during the early 1970s: legal restrictions, market conditions, and the federal government's policy stance. Our review of the evidence suggests that the rapid increase in the number of HMOs during this period was primarily due to favorable market conditions in certain areas of the country combined with a highly encouraging federal policy toward HMOs. Legal restrictions do not appear to have been as serious a barrier to HMO development as was earlier believed. In 1973-74, major new legislation was enacted at both the federal and state levels, ostensibly to encourage HMO development. Our review of this legislation suggests that, while it removes many of the old legal requirements which apparently were not serious barriers to HMO development, the new legislation imposes a host of new conditions and requirements on HMO participation in the health care marketplace. Ironically, some of these new features may impede the operation of the very market forces which encouraged the earlier HMO growth.

Consumer Behavior↗