Helen L. Smits

Can Medicare prospective payment survive the ICD-9-CM disease classification system?

The Medicare prospective payment system represents a fundamental change in hospital payment. The diagnosis-related group (DRG) patient classification scheme serves as the modifier of payment for this system. The DRG definitions are, in turn, based on the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM). Deficiencies in the ICD-9-CM coding system directly affect the equity of the Medicare payment system. A review of the ICD-9-CM system identifies three principal problems: the inability of the system to reflect clinically important patient attributes adequately; the use of outcome, rather than approach, to code surgical procedures; and the blurring of clinical specificity by the adoption of certain coding rules. If these deficits in coding specificity are not corrected, it is unlikely that DRGs will adequately distinguish clinically unique types of patients. This inability to differentiate among patients threatens to undermine the equity of Medicare payments. Physicians must become more aware of disease coding and more involved in its development and implementation.

The Primary-Care Practitioner — Specialist or Jack-of-All-Trades

Primary-care physicians, too often viewed as low-level generalists, are more appropriately thought of as specialists whose work demands specific skills. These physicians function as managers, advocates, educators, and counselors for their patients while also serving as co-ordinators of other professionals involved in primary care. The basis for education in primary care should be a recognition of the specialized nature of the work that primary-care physicians perform. Faculty members in primary-care programs should themselves be primary-care physicians; these educators deserve the same titles and status given other clinical specialists within the academic community. The setting of standards for primary-care practice and the design of research into areas such as the quality of care are tasks that should be undertaken by, or in collaboration with, physicians who are primary-care specialists.

Care of the Aged: An English Lesson?

Abstract A comparison of the services provided for the elderly in Great Britain and the United States shows the impact that organized medical care has on day-to-day clinical activities. The British...

Case mix of public patients in skilled nursing facilities in Connecticut.

The case mix of publicly funded residents in 73 skilled nursing facilities (SNFs) in two Connecticut counties was examined. Data collected in 1980-1981 for utilization review by a professional standards review organization were used for the analysis. The findings indicate that considerable variation exists in case mix across the SNFs. Medicaid per diem rates, which are based on historic costs, have a low and negative correlation with case mix. Case mix indices are significantly higher for rural facilities, with a for-profit type of ownership, and with less than 75% of the bed days devoted to Medicaid residents.

Women, Health, and Development: An American Perspective

Excerpt The director-general of the World Health Organization (WHO) has just issuedWomen, Health and Development(1). This brief, clear document, published to mark the end of the United Nations Deca...