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INSURANCE PRINCIPLES AND THE DESIGN OF PROSPECTIVE PAYMENT SYSTEMS

JOURNAL OF HEALTH ECONOMICS 1988年第3期7卷 215-237页

作者： ELLIS, RP MCGUIRE, TG BOSTON UNIV BOSTONMA 02215 USA

This paper applies insurance principles to the issues of optimal outlier payments and designation of peer groups in Medicare's case-based prospective payment system for hospital care. Arrow's principle that full insurance after a deductible is optimal implies that, to minimize hospital risk, outlier payments should be based on hospital average loss per case rather than, as at present, based on individual case-level losses. The principle of experience rating implies defining more homogenous peer groups for the purpose of figuring average cost. The empirical significance of these results is examined using a sample of 470,568 discharges from 469 hospitals.

关键词：成本及成本分析数据收集绝对免赔额与共同保险诊断相关患者组/经济学经济学医院/统计学和数值数据保险住院/统计学和数值数据 Medicare 预期支付系统/组织和管理危险因素美国

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Assessing Medicare's prospective payment system for hospitals.

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Medical care review 1991年第2期48卷 167-206页

作者： Chulis, G.S. Health Care Financing Administration Baltimore MD United States

The Medicare prospective payment system for hospitals was created to slow the growth of government spending on health care. This analysis has shown that the program has accomplished its cost-containment objective in the first five years of its existence. The average length of hospital stay has dropped sharply under PPS, reducing hospital costs. These reduced costs combined with payments based on higher pre-PPS historic costs have given hospitals high profits in the early years of PPS. One of the expected but unwanted outcomes, more admissions, has never occurred. The unexpected rop in admissions under PPS has been responsible for government savings on Medicare inpatient care. Although Medicare outpatient hospital and physician expenditures have grown at fast rates during PPS, there is no evidence in aggregate date that they have grown any faster because of inpatient care shifting to avoid PPS payment controls. The Medicare PPS savings have extended to all U.S. hospital spending, which has grown at much slower rates since the implementation of PPS. There have also been negative outcomes from PPS, and some questions posed about PPS remain unanswered. The inflation in "DRG creep" or upcoding that was predicted for PPS did occur. The government has since washed much of this code inflation out of the permanent payment base, but this phenomenon may not be a self-limiting problem, as was widely hoped. To date there is no convincing evidence of poorer quality of care under PPS, but most of the available evidence is based on mortality studies, which have limited use in measuring changes in quality of care. While PPS has helped to slow the growth in Medicare and national hospital spending, it has not had an appreciable effect on the rate of growth in the nation's total health spending. Although it was unintended, PPS has been providing a natural experiment on the issue of whether increased cost sharing dampens demand for health care services. By slowing the growth rate of inp

关键词：数据收集经济学医院/发展趋势卫生经费支出/发展趋势住院/发展趋势 MedicareA部/组织和管理方案评价预期支付系统/组织和管理统计数据美国

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The Medicare Critical Access Hospital program: The first year

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JOURNAL OF RURAL HEALTH 1999年第1期15卷 61-66页

作者： Reif, SS Ricketts, TC Univ N Carolina Sheps Ctr Hlth Serv Res Chapel Hill NC 27599 USA

The Medicare Critical Access Hospital (CAH) program, part of the Balanced Budget Act of 1997, is a nationwide limited service hospital program. Structured interviews were conducted in August and September 1998 with key people in state offices of rural health, state hospital associations, departments gf health or departments of facility licensing in all 50 states to assess their progress in the development of the CAH program. The majority of states expressed interest in the CAH program. Twenty-one states were moving formally toward involvement in the program. States that had developed or were in the process of developing a state plan estimated that between 183 to 227 hospitals would convert to CAHs in the next one to two years. States that were the most successful with plan de development appeared to be states that participated in the Essential Access Community Hospital/Rural Primary Care Hospital program, states where there was dialogue about the possibility of a limited service hospital program and states with widespread support in the state. A pressing need for most states is for reliable fiscal consulting or analysis that could be applied to individual hospitals that are considering conversion to CAHs. The CAH program shows promise for successful implementation based on its early results.

关键词：预算/立法和法学卫生服务易得程度/组织和管理卫生服务研究医院公立/经济学医院公立/组织和管理医院乡村/组织和管理医院慈善/经济学医院慈善/组织和管理缺医地区 Medicare/组织和管理需求估价/组织和管理试点项目初级卫生保健/组织和管理规划制订方案评价预期支付系统/组织和管理问卷调查偿还途径/组织和管理美国人类

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INSURANCE ASPECTS OF DRG OUTLIER PAYMENTS

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JOURNAL OF HEALTH ECONOMICS 1988年第3期7卷 193-214页

作者： KEELER, EB CARTER, GM TRUDE, S RAND CORP 1700 MAIN STSANTA MONICACA 90406 USA

As part of the prospective payment system, the government pays 'outlier' payments for especially long or expensive cases. These payments can be viewed as insurance for the hospital against excessive losses. They mitigate problems of access and underprovision of care for the sickest patients, and provide additional payments to the hospitals that take care of them, thereby making payments to hospitals more equitable. This paper characterizes the outlier payment formulae that minimize risk for hospitals under any fixed constraints on the sum of outlier payments and minimum hospital coinsurance rate. We then simulate per-case payments for a policy that did not include any outlier payments, the current outlier policy, and several other policies that minimize risk subject to different coinsurance constraints. The current outlier policy achieves each of its goals to at least some extent, but more insurance could be provided without lessening attainment of the other goals. We also discuss some problems with the implementation of the current policy, such as its reliance on day outliers.

关键词：保险统计分析 Medicare与Medicaid服务中心(美国) 绝对免赔额与共同保险诊断相关患者组/经济学经济学医院/统计学和数值数据保险住院/统计学和数值数据 Medicare 模型统计学预期支付系统/组织和管理危险因素美国

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Assessing the strategy-performance paradigm: Implications for organizational adaptation in discontinuous environments for home health care providers

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Health Marketing Quarterly 1997年第4期14卷 27-44页

作者： Westbrook, Kevin W. Department of Marketing Fogelman College of Business and Economics University of Memphis Memphis TN 38152 United States

Home health care agencies are on the brink of experiencing prospective payment systems which will prove to be a major environmental shift. What will be the best strategy to offset the effects of prospective payment systems? Longitudinal studies of hospitals facing similar pressures may offer the best solution. This paper offers an attempt to address whether proactive or low cost strategies will provide home health agencies with higher firm performance after prospective payment systems. © 1997 by The Haworth Press, Inc. All rights reserved.

关键词：卫生保健费用家庭保健机构/经济学家庭保健机构/组织和管理家庭医疗保健服务/经济学模型组织管理组织改革规划技术预期支付系统/组织和管理美国人类

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Synthesis: Experience with diagnosis related groups

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International Journal of Technology Assessment in Health Care 1986年第1期2卷 77-81页

作者： Young, Donald A. Prospective Payment Assessment Commission Washington D.C. 20024 300 7th Street S.W. Room 301-B United States

The Medicare prospective payment system (PPS) for inpatient hopital service was enacted in 1983. It uses a classification based on diagnosis-related groups (DRGs) to determine payment for services provided.

关键词：诊断相关患者组预期支付系统/组织和管理偿还途径/组织和管理技术评估生物医学/经济学美国

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Technology assessment for public payment policy: the Prospective Payment Assessment Commission (PROPAC).

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International journal of technology assessment in health care 1985年第3期1卷 756-759页

作者： Burns, A.K.

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CHANGES IN RATES OF UNSCHEDULED HOSPITAL READMISSIONS AND CHANGES IN EFFICIENCY FOLLOWING THE INTRODUCTION OF THE MEDICARE PROSPECTIVE PAYMENT SYSTEM - AN ANALYSIS USING RISK-ADJUSTED DATA

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EVALUATION & THE HEALTH PROFESSIONS 1991年第2期14卷 228-252页

作者： DESHARNAIS, S HOGAN, AJ MCMAHON, LF FLEMING, S MICHIGAN STATE UNIV E LANSINGMI 48824 UNIV MICHIGAN MED CTRANN ARBORMI 48109 UNIV MISSOURI COLUMBIAMO 65201

The purpose of this study was to analyze changes in rates of unscheduled readmissions and changes in technical efficiency following the introduction of the Medicare Prospective Payment System (PPS). We developed the RiskAdjusted Readmissions Index (RARI), which allowed us to make comparisons in rates of unanticipated readmissions across hospitals and over time. Data envelopment analysis (DEA), a linear programming technique, was used to measure changes in technical efficiency by comparing the inputs used and the outputs produced across a cohort of hospitals, while adjusting for changes over time in case mix and case complexity. Rates of unscheduled readmissions and efficiency scores were computed for a sample of 245 hospitals for each year. Although both readmission rates and efficiency scores increased for most hospitals, there was no evidence that those hospitals that experienced the greatest increases in efficiency had the largest increases in their rates of unscheduled readmissions.

关键词：效率评价研究医院/利用 Medicare/组织和管理模型统计学病人再入院/统计学和数值数据预期支付系统/组织和管理危险美国人类

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