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Biomedical subjects

W B Schwartz

Publications and source records attributed to W B Schwartz.

At least 19 recordsLinked to original sources
PubMed1991

Hospital cost containment in the 1980s. Hard lessons learned and prospects for the 1990s.

BACKGROUND: A key strategy used to contain hospital costs during the 1980s was to reduce the total number of admissions and average lengths of stay. We assessed the magnitude of the savings achieved, the effect of the reductions on the rate of increase in costs, and the prospects for future savings through reductions in the number of days patients spend in the hospital (inpatient days). METHODS: Using data from the American Hospital Association and the Health Care Financing Administration, we calculated the savings in the total number of inpatient days as the deviation from the historical increase in the number of inpatient days per year. We then estimated the real increase in costs that would have been observed if the reduction in the number of inpatient days had not occurred; we defined this value as the "underlying" rate of increase in costs. Finally, we compared the rates of increase in hospital reimbursement for Medicare beneficiaries and patients not covered by Medicare (non-Medicare patients). RESULTS: The total number of inpatient days per year decreased by 28 percent, in aggregate, between 1981 and 1988. The annual reduction was greatest in 1984 and 1985 and became progressively smaller in each subsequent year; by 1988 there was virtually no further reduction in the total number of inpatient days. The brief slowing of the increase in costs in the mid-1980s can be attributed entirely to the reduction in the number of inpatient days per year. The underlying rate of increase in costs was thus unaffected by efforts to contain spending. An increased number of outpatient visits partially offset the savings that resulted from the reduction in the number of inpatient days. This increase persisted even when the savings due to the lower number of inpatient days dwindled, and it virtually eliminated any dollar savings during the latter part of the 1980s. Between 1976 and 1982, Medicare spending on services provided by acute care hospitals rose by 9.2 percent per year in real terms, whereas non-Medicare expenditures rose by only 4.6 percent. This pattern has been reversed in recent years; in 1987-1988, Medicare spending rose by only 0.6 percent per year, whereas non-Medicare spending rose by 9 percent. CONCLUSIONS: Our findings suggest that the era of easy reductions in the number of inpatient days, with the associated attenuation of rising costs, is largely over. If further reductions in inpatient days are accompanied by an increase in the amount of ambulatory care similar to that during the past few years, the net savings will probably be negligible. Once the potential savings due to reductions in the number of inappropriate inpatient days has been exhausted, real hospital costs can be expected to rise, unless other effective measures to contain costs are implemented.

Ambulatory Care↗
PubMed1990

Rationing health care: the choice before us.

Rapid technological advances and upward pressure on wages of hospital personnel are leading to a steady increase in health care spending that is absorbing an ever-larger fraction of gross national product. Eliminating inefficiencies in the system can provide brief fiscal relief, but rationing of beneficial services, even to the well-insured, offers the only prospect for sustained reduction in the growth of health care spending. The United States, which has negligible direct experience with rationing, can learn about choices it will face from the experience of Great Britain where health care has been rationed explicitly for many years.

Cost Control↗
PubMed1990

No evidence of an emerging physician surplus. An analysis of change in physicians' work load and income.

Analysis of physicians' work patterns and income between 1982 and 1987 provides strong evidence that the demand for physicians' services has risen at least as quickly as physician supply. Aggregate hours spent by US physicians who provide patient care rose by 21%, and aggregate real net income rose by more than 30% during a period in which the supply of physicians grew by only 16%. The aggregate number of visits rose by only 9%, indicating that the time spent per patient encounter rose sharply, presumably as a result of technological change and the increased complexity of care. Recently released data for 1988 are consistent with these trends. Our findings are inconsistent with the prediction by the Graduate Medical Education National Advisory Committee that there would be a large physician surplus by the year 1990. Moreover, if the upward trend in demand for physicians' services continues, as seems probable, a physician surplus should not develop in the foreseeable future. Only extensive rationing of beneficial services would be expected to alter this projection.

Data Collection↗
PubMed1989

Physicians who have lost their malpractice insurance. Their demographic characteristics and the surplus-lines companies that insure them.

The present study analyzes demographic data on 920 physicians who lost their coverage and applied to a "surplus-lines" company that insures essentially all applicants. Our analysis reveals that (1) some specialties are heavily overrepresented in the surplus-lines pool, (2) physicians aged 45 to 54 years are also overrepresented, (3) board certification is seen as frequently in the surplus-lines group as in the US physician population, and (4) the percentage of foreign medical graduates in the surplus-lines pool is virtually the same as that in the US physician population. A model of the actuarial process by which claims data can lead to termination of standard coverage suggests that disproportionate representation of high-risk specialties is not simply a function of a high average claims rate. We also show that, in contrast to joint underwriting associations, surplus-lines companies impose high premiums, large deductibles, and restrictions on practice, all of which are likely to reduce the frequency of negligent behavior.

Actuarial Analysis↗
PubMed1979

Decision analysis.

Explore the source record for details and available documents.

Decision Making↗
PubMed1979

A redefinition of normal acid-base equilibrium in man: carbon dioxide tension as a key determinant of normal plasma bicarbonate concentration.

It has been shown recently that normal acid-base equilibrium in the dog is characterized by a strong positive correlation between plasma bicarbonate concentration and PCO2. The present study was undertaken to examine the possibility that a similar relationship between normal levels of PCO2 and plasma bicarbonate might be present in man. The results indicate that values for bicarbonate within the normal range are highly dependent upon the prevailing level of PCO2 ([HCO3-] = 0.36 PaVCO2 + 10.4; r = 0.73). Thus, approximately 50% of the normal variance in bicarbonate concentration is explained simply by the variance in PCO2. The joint confidence region for bicarbonate concentration and PCO2, that can be derived from these data provides a new and more rigorous definition of normal acid-base equilibrium in man.

Acid-Base Equilibrium↗
PubMed1979

Effect of natural variations in PaCO2 on plasma [HCO3-] in dogs: a redefinition of normal.

Graded degrees of both chronic hyper- and hypocapnia are known to induce renal responses that significantly alter plasma bicarbonate concentration. These findings have raised the possibility that even normal variations in PaCO2 play an important role in determining the exact level of bicarbonate in plasma. To test this hypothesis, we examined the relationship between resting levels of PaCO2 and the plasma bicarbonate concentration in two groups of normal dogs, one ingesting a normal salt diet and the other a salt-restricted diet. The results indicate that values for bicarbonate within the normal range are highly dependent on the prevaling level of carbon dioxide tension ([HCO3-] = 0.35 PaCO2 + 9.0, r = 0.72). Accordingly, approximately 50% of the normal variance in bicarbonate concentration is explained simply by the variance in PaCO2. The joint confidence region for bicarbonate concentration and PaCO2, which can be derived from these data, provides a new and more rigorous definition of the normal range for acid-base values in the dog.

Acid-Base Equilibrium↗
PubMed1978

Doctors, damages and deterrence. An economic view of medical malpractice.

Damages awarded in a malpractice suit must be viewed not only as compensating the victim but also as deterring health-care providers from negligent behavior. Economic analysis of the malpractice system indicates that awards can send a signal to providers that informs them how much to invest in avoiding mishaps. The malpractice system is beset by difficulties, but not the ones commonly incriminated. The signal to the physician, as determined by the number of claims and size of awards ("expected damages"), appears to be insufficient for ideal deterrence. Moreover, the deterrence signal is attenuated because malpractice premiums are set for groups of physicians, not for individuals according to their record of previous malpractice incidents. Replacing the present tort system with a no-fault insurance scheme would not necessarily be cheaper, and might well abolish the deterrent signal or distort clinical decision making.

Cost-Benefit Analysis↗
PubMed1978

The diagnostic importance of the normal finding.

When a diagnostic test is reported as normal, the clinician generally uses it only to rule out certain diseases. However, if properly interpreted, the normal value may help to differentiate among diagnoses that yield normal results with different frequencies. A simple method permits the extraction of such information. The physician estimates the probability of various diagnoses and then combines these estimates with the anticipated frequency of negative results for each disease under consideration.

Adult↗
PubMed1978

The nature of the renal response to chronic disorders of acid-base equilibrium.

The rate of acid excretion by the kidney appears to be determined by factors regulating the site and the rate of sodium reabsorption, rather than by a homeostatic mechanism that responds to systemic pH. This hypothesis, although unconventional, is supported by much experimental evidence, and it accounts for a wide variety of clinical and physiologic findings that heretofore have been difficult or impossible to explain.

Absorption↗
PubMed1977

The maladaptive renal response to secondary hypocapnia during chronic HCl acidosis in the dog.

It has generally been thought that homeostatic mechanisms of renal origin are responsible for minimizing the alkalemia produced by chronic hypocapnia. Recent observations from this laboratory have demonstrated, however, that the decrement in [HCO(-) (3)], which "protects" extracellular pH in normal dogs, is simply the by-product of a nonspecific effect of Paco(2) on renal hydrogen ion secretion; chronic primary hypocapnia produces virtually the same decrement in plasma [HCO(-) (3)] in dogs with chronic HCl acidosis as in normal dogs (Delta[HCO(-) (3)]/DeltaPaco(2) = 0.5), with the result that plasma [H(+)] in animals with severe acidosis rises rather than falls during superimposed forced hyperventilation. This observation raised the possibility that the secondary hypocapnia which normally accompanies metabolic acidosis, if persistent, might induce an analogous renal response and thereby contribute to the steady-state decrement in plasma [HCO(-) (3)] observed during HCl feeding. We reasoned that if sustained secondary hypocapnia provoked the kidney to depress renal bicarbonate reabsorption, the acute salutary effect of hypocapnia on plasma acidity might be seriously undermined. To isolate the possible effects of secondary hypocapnia from those of the hydrogen ion load, per se, animals were maintained in an atmosphere of 2.6% CO(2) during an initial 8-day period of acid feeding (7 mmol/kg per day); this maneuver allowed Paco(2) to be held constant at the control level of 36 mm Hg despite the hyperventilation induced by the acidemia. Steady-state bicarbonate concentration during the period of eucapnia fell from 20.8 to 16.0 meq/liter, while [H(+)] rose from 42 to 55 neq/liter. During the second phase of the study, acid feeding was continued but CO(2) was removed from the inspired air, permitting Paco(2) to fall by 6 mm Hg. In response to this secondary hypocapnia, bicarbonate concentration fell by an additional 3.0 meq/liter to a new steady-state level of 13.0 meq/liter. This reduction in bicarbonate was of sufficient magnitude to more than offset the acute salutary effect of the hypocapnia on plasma hydrogen ion concentration; in fact, steady-state [H(+)] rose as a function of the adaptive fall in Paco(2), Delta[H(+)]/Delta Paco(2) = -0.44. That the fall in bicarbonate observed in response to chronic secondary hypocapnia was the result of the change in Paco(2) was confirmed by the observation that plasma bicarbonate returned to its eucapnic level in a subgroup of animals re-exposed to 2.6% CO(2). These data indicate that the decrement in plasma [HCO(-) (3)] seen in chronic HCl acidosis is a composite function of (a) the acid load itself and (b) the renal response to the associated hyperventilation. We conclude that this renal response is maladaptive because it clearly diminishes the degree to which plasma acidity is protected by secondary hypocapnia acutely. Moreover, under some circumstances, this maladaptation actually results in more severe acidemia than would occur in the complete absence of secondary hypocapnia.

Acidosis↗
PubMed1976

Strategies for financing national health insurance: who wins and who loses.

Two sources of funds are available to underwrite the costs of any national health-insurance plan: prepayments (premiums, payroll taxes and income taxes) and out-of-pocket payments (coinsurance and deductibles). The extent to which taxes rather than premiums are used to finance an insurance program will be the major determinant of how large a share of the costs of health care will be borne by higher-income groups. The extent to which coinsurance and deductible provisions are reduced or waived for low-income persons will have a less important, but still substantial, role in determining how the costs of a program are distributed. These financing principles, once understood, provide a basis for the design of health-insurance legislation that will achieve any pattern of income redistribution that may be desired.

Deductibles and Coinsurance↗