and A.M. Epstein. In a further disaggregation of the total sample of disabled older persons, in which we examined changes of specific case-mix and post-acute care subgroups, we found statistically significant differences at the .05 level in only two cases. While this group is relatively healthier in terms of chronic functional and health problems they will still experience, at a lower rate, serious and acute medical problems. While also based on episodes rather than beneficiaries, this analysis keyed events to a hospital admission. The earliest of the ACA's provisions related to provider reimbursement have slowed growth in fee-for-service payment levels. Prospective payment systems are intended to motivate providers to deliver patient care effectively, efficiently and without over utilization of services. Our study also suggested that quality of care, in terms of hospital readmissions and mortality, were not systematically affected by PPS. how do the prospective payment systems impact operations? Unlike other studies assessing PPS effects, our study population focused on disabled, noninstitutionalized. However, the increase in six month institutionalization rates suggested that the patients entering nursing homes at discharge were not subsequently regaining the skills needed for independent living. This type is also prone to hip and other fractures; the relative risks of hip fracture in this group, for example, is three times greater than the average disabled person. These results are consistent with findings by other researchers (DesHarnais, et al., 1987). While consistent with findings of other researchers (Krakauer, 1987, DesHamais, et al., 1987), this result appears to be counterintuitive, in light of the incentives of PPS for higher admission rates and shorter lengths of stays (Stem and Epstein, 1985). It should be noted that, unlike the results of Table 4, which included rates of hospital discharge resulting in death, the present analysis includes deaths after discharge from the hospital as well as deaths occurring in the hospital. Abstract and Figures The reform of provider payment systems, from retrospective to prospective payment, has been heralded as the right move to contain costs in the light of rising health. Third-quarter data from a cohort of 729 short-term acute care hospitals for 1980-1984 were used in this analysis. Medicare's DRG system is called the Medicare severity diagnosis-related group, or MS-DRG, which is used to determine hospital payments under the inpatient prospective payment system (IPPS). Our specific aims were to measure changes in Medicare service use and to evaluate the effects of these changes on quality of care in terms of hospital readmission and mortality. Thus the whole distribution by case-mix type has been altered by the sorting out of service venues due to the impact of PPS. Post Acute HHA Use. The governing agency, the Health Care Financing Administration, switched from a retrospective fee-for-service system to a prospective payment system (PPS). Their hypothesis was that, after PPS, elderly patients hospitalized for hip fractures would receive shorter, less care-intensive hospitalization and would be institutionalized (in nursing homes) more frequently. These groups represent distinct subsets of medical and functional states of Medicare beneficiaries reflecting the multiple comorbidities of elderly persons which may be expected to be associated with service use patterns and possible negative outcomes of care such as hospital readmission and mortality. The study found that expected reductions in lengths of hospital stays occurred under PPS, although this reduction was not uniform for all admissions and appeared to be concentrated in subgroups of the disabled population. With technology playing such an . While increased SNF and HHA use might be viewed as an intended consequence of PPS, there has been concern that PPS induced changes in the duration and location of care would affect quality of care received by Medicare beneficiaries. https:// Table 3 shows a shift in the proportion of cases by service episodes of each of the four types between 1982 and 1984. the community non-disabled elderly, and c.) those persons who were in long term care institutions at the time the sample was defined. This file will also map Zip Codes to their State. First, Grade of Membership analysis was used to derive subgroups of the population according to patient characteristics, and to measure case-mix changes between the pre- and post-PPS periods. This study examined hospitalization rates and hospital lengths of stay and location of death of the Medicaid patients. To be published in Health Care Financing Review, 1987, Annual Supplement. For these cases, non-Medicare nursing home and other post-acute services might have been received, although we are not able to make that distinction. Life table methodologies were employed for several reasons. Fourth quart For example, given that the oldest-old case-mix group was characterized by a high risk of cancer, some might have received community based hospice care. The Social Security Amendments of 1983 mandated the PPS payment system for hospitals, effective in October of Fiscal Year 1983.12 Case-mix information on the 1982 and 1984 samples were derived through Grade of Membership analysis of the pooled 1982 and 1984 samples (Woodbury and Manton, 1982; Manton, et al., 1987). 1982: 194 days1984: 199 days* Adjusted for competing risks of death and end of study. 1987. For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) providers, including physicians, other practitioners and suppliers, go to the Provider Center (see under "Related Links" below). and K.G. Table 4 presents the patterns of Medicare hospital events for the two time periods, after adjusting for the events for which the discharge outcome was not known because of end-of-study. First, an important dimension of the comparisons of Medicare service use between 1982-83 and 1984-85 was the duration of specific services (e.g., hospital length of stay). First, the expected use of post-acute HHA was expected in light of PPS incentives to discharge patients to lower levels of care. Presented at the APHA Annual Meeting, New Orleans, Louisiana, October 20. For example, there might have been substitution between hospital and SNF care for the mildly disabled, but for the heart and lung disease patients, no differences in hospital length of stay was observed. In addition to employing the GOM subgroups to adjust for overall utilization changes before and after PPS, we examined differences in the effects of PPS on the specific subgroups among the disabled elderly population. The data set that we assembled for this study provided a basis for addressing analytical dimensions that are not generally available on billing records and hospital discharge abstracts alone (Iezzoni, 1986). The GOM profiles represent subgroups of the total samples which were relatively homogeneous in terms of these characteristics. Slight increases in mortality risks were observed for hospital episodes followed by HHA care, both in the short term and for the total observation period of one year. Finally, hospital readmissions did not change significantly between the pre- and post-PPS periods, although the measure of hospital readmission that was used was very limited, i.e., readmission to the same hospital during the same quarter of observation. Table 5 presents the discharge patterns of individuals who experienced Medicare SNF use pre- and post-PPS and the length of stay in Medicare SNFs. A higher rate of other episodes terminating in deaths among the oldest-old suggests that Medicare service use changed for this group. .gov Fifty-six (56) medical conditions, ADLs and IADLs were used in this analysis. STAY IN TOUCHSubscribe to our blog. All payment methods have strengths and weaknesses, and how they affect the behavior of health care providers depends on their operational Changes to the inpatient-only (IPO ** One year period from October 1 through September 30. Hence, the length of stay of a third hospital admission for a given beneficiary, for example, would enter the calculation of average hospital length of stay. This week you will, compare and contrast prospective payment systems with non-prospective payment systems. Table 11 presents the patterns of service use for the "Severely Disabled" group, which was characterized by heavy ADL dependency, neurological problems, stroke, and senility. Table 1 shows that nondisabled, noninstitutionalized persons had shorter hospital stays than either the community disabled or the institutionalized. Results of our study provided further insights on the effects of PPS on utilization patterns and mortality outcomes in the two periods of time. Detailed tables on all hospital, SNF and HHA patterns are included in Appendix B. Similar to the patterns of hospital readmission risks found in Table 12, Table 14 shows an increased proportion of deaths occurring within 30 days of hospital admission in 1984 which was offset by a decreased proportion of deaths in succeeding intervals of time after admission. Marginally significant differences (p = .10) were detected for SNF episodes, which decreased in LOS. 1987. We adjusted for differences in mortality as competing risks by employing cause elimination life table methodology. It found that, overall, PPS had no negative effect on patient outcomes and did not alter an already existing trend toward improved processes of care. Our overall findings are consistent with the notion that PPS incentives result in some discharges to nursing homes being readmitted to hospitals, although the overall pattern of readmissions were not significantly different in the two time periods. 2. The concept has its roots in the 1960s with the birth of health maintenance organizations (HMOs). This result was consistent with those of Krakauer (1987) and Conklin and Houchens (1987). For example, all of the hospital episodes in our sample, whether they were the first, second or third hospitalization during the observation window, were included as an individual unit of observation. We like new friends and wont flood your inbox. There were no statistically significant differences before and after PPS in the patterns of hospital, SNF and HHA episodes. Statistically significant differences at between the .10 and .05 levels were found for this subgroup of deaths. Hospital readmissions refer to any pair of hospital stays (e.g., first and second, second and third, etc.). PPS replaced the retrospective cost-based system of pay Second, we examined the risk of readmission as a function of duration of time after the initiating admission. This distribution across time periods allowed before-and-after comparisons among patient groups. However, the impact on mortality of discharge in unstable condition did not outweigh other quality improvements, because overall mortality fell. Hence, our decision rule probably produced lower rates of post-acute Medicare SNF and HHA utilization rates. Explain the classification systems used with prospective payments. The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. 90 days after hospital admission, the mortality risks of hospital episodes followed by SNF use decreased from 23.7 percent to 14.2 percent. The patients studied were those aged 65 years or older with a new fracture. This result is analogous to our comparison of the 1982-83 and 1984-85 windows. means youve safely connected to the .gov website. This uncertainty has led to third-party payers moving towards prospective payment methodologies. Type I, which we will refer to as "Mildly Disabled," has only a minimum of long-term health and functional status problems, with the most prevalent conditions being rheumatism and arthritis. In addition, we employed the second output of GOM analysis, the degree to which individual cases resemble each of the GOM profiles to determine if a shift occurred in the case-mix of episodes of Medicare hospital, SNF and HHA care between the pre- and post-PPS periods. Other measures included length of hospital stay, status at discharge, discharge destination (home or other care facility), prolonged nursing-home stays, and readmissions. prospective payment systems or international prospective payment systems. Hospitalization data were available from the Wisconsin Medicaid program for the period from 1982 through 1984, while mortality data were obtained for the years 1980 through 1985. The expected number of days after hospital admission to death were identical for the pre- and post-PPS periods. To illustrate, we conducted parallel analyses to the ones presented here of all experience in calendar years 1982 and 1984. Thus, an groups experienced notable declines in hospital LOS with the institutionalized having the largest decline (i.e., 2.0 days).
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