Jenifer L. Ehreth

The Development and Evaluation of Hospital Performance Measures for Policy Analysis

The purpose of this study was to develop and evaluate hospital performance measures to include aspects of hospital behavior beyond the traditional use of hospital profit margins for policy analysis. A number of measures have been used in the literature that are purported to reflect a variety of hospital behaviors. The reliability and validity of these and new measures were assessed using descriptive statistics and factor analysis on a sample of hospitals for a 3-year period. The sample consisted of all hospitals for which there were Medicare Cost Report and balance sheet data during the federal fiscal years 1987 through 1989. Using a subset of three hospital groups, 33 measures were evaluated, from which five were selected to represent the critical aspects of hospital performance important for policy analysis. The measures are: TEM, a new technical efficiency measure using data envelopment analysis techniques; the current ratio, depicting short-term financial performance; the ratio of longterm debt-to-net fixed assets, representing long-term viability; total margin, portraying profitability; and Medicare margin, characterizing Medicares contribution to hospital financial position. Each represents different aspects of hospital efficiency and financially viability.

The evaluation of the Henry J. Kaiser family foundation's community health promotion grant program: Design

The Kaiser Family Foundations Community Health Promotion Grant Program (CHPGP) provides funding and technical assistance in support of community-based efforts to prevent major health problems. The first phase of the program was implemented in 11 communities in the western United States. This paper describes the evaluation design of the CHPGP in the West, the methods of data collection, and the baseline comparability of intervention and control communities. Major features of the evaluation design include: (1) the randomization of qualified communities making application into funded and unfunded comparison groups; (2) a second set of matched control communities for some intervention sites; (3) data gathering through repeated surveys of community residents (probability samples of adults and adolescents) and institutions (health-related organizations and randomly sampled grocery stores and restaurants); and (4) the use of secondary data to monitor health events. Selected baseline data show that intervention and control communities differ in racial/ethnic composition, but relevant health behaviors and ratings of community activation for health promotion appear comparable.

Methods of Determining the Cost of Health Care in the Department of Veterans Affairs Medical Centers and Other Nonpriced Settings

Cost is increasingly important in the evaluation of health care. Though charges are often used as a proxy for cos4 some health care systems such as the Veterans Administration do little or no billing. This article describes, presents examples of and evaluates four options for determining the cost of care within the Department of Veterans Affairs: measuring input costs, the Departmen ts cost accounting system, the reimbursement system, and use of charges from a surrogate health care facility. Each approach is evaluated for accuracy, ability to compare the costs of different treatments, and effort required to estimate cost.

A Description Of The Content Of Army Family Practice

Background: For decisions about residency curricula and downsizing the US Army medical corps, decision makers must know the practice content of the various specialties. Little is known about the content of Army family practice. The purpose of our study was to describe the content of Army family practice. Methods: We analyzed a random sample of 28,849 family practice encounters from the US Army Ambulatory Care Data Base Study. Variables included patient demographics, diagnoses, visit duration, procedures, and medical facility. Patient age and visit duration were compared using analysis of variance; facility profiles were compared by age category and sex of patients, family member position, and procedure frequency using chi-square analysis. Diagnostic content of the facilities was compared by both chi-square and Kendall’s tau B tests. Results: The typical patient was a 26-year-old woman. The 25 most frequent diagnoses accounted for three-fourths of all encounters, with variation by patient age. The majority of visits did not include a procedure, but procedure frequency varied by patient age and diagnostic certainty. Mean visit duration was 16.4 minutes and varied by age. There were differences among the sites for all variables. Conclusions: Army family physicians see patients of all ages, of whom more are the family members of soldiers than the soldiers themselves; they frequently do procedures and are usually certain of their diagnoses, which include a broad spectrum of illnesses. Army family physicians are flexible, adapt to local patient and environmental needs, and are uniquely qualified to form the basis of Army medicine.

THE IMPLICATIONS FOR INFORMATION SYSTEM DESIGN OF HOW HEALTH CARE COSTS ARE DETERMINED

As the costs of health care assume increasing importance in national health policy, information systems will be required to supply better information about how costs are generated and how resources are distributed. Costs, as determined by accounting systems, often are inadequate for policy analysis because they represent resources consumed (expenditures) to produce given outputs but do not measure forgone alternative uses of the resources (opportunity costs). To accommodate cost studies at the program level and the system level, relational information systems must be developed that allow costs to be summed across individuals to determine an organizations costs, across providers to determine an individual patients costs, and across both to determine system and population costs. Program level studies require that cost variables be grouped into variable costs that are tied to changes in volume of output and fixed costs that are allocated rationally. Data sources for program-level analyses are organizational financial statements, cost center accounting records, Medicare cost reports, American Hospital Association surveys, and the Department of Veterans Affairs (VA) cost distribution files. System-level studies are performed to predict future costs and to compare costs of alternative modes of treatment. System-level analyses aggregate all costs associated with individuals to produce population-based costs. Data sources for system-level analyses include insurance claims;n Medicare files; hospital billing records; and VA inpatient, outpatient, and management databases. Future cost studies will require the assessment of costs from all providers, regardless of organizational membership status, for all individuals in defined populations.

A Comparison Of The Content Of Army Family Practice With Nonfederal Family Practice

Background: To assist with planning for education and practice, family physicians should know the practice content of their practices. The present study compared the content of nonfederal family practice with Army family practice to explore their differences. Methods: This was a secondary analysis that compared the similar variables within two national data sets: The National Ambulatory Medical Care Survey and the Army’s Ambulatory Care Data Base. Results: Army patients were younger and more likely to be female than were nonfederal patients. Army family physicians spent more time with patients in all groups than did nonfederal family physicians. While 12 of the top 20 diagnosis clusters of each sector were the same, there were differences found in the percentages of total visits contained within the top 20 clusters. Conclusions: Both nonfederal and Army family practice have a wide variation in patients and diagnoses. The two sectors are different in patient age and the frequency of different diagnoses. Knowledge of these differences can assist with planning.

The financial incentives in a shift to capitation for state mental health services

The State of Washington’s Mental Health Division (MHD) is the State agency responsible for providing state sponsored mental health services. In 1993, the MHD received a Health Care Financing Administration (HCFA) waiver to implement a statewide system of managed care for outpatient mental health rehabilitation services. Payments were to be prepaid and capitated and based on the numbers of clients in each of at least 3 payment tiers. This paper describes financial findings from a HCFA-mandated evaluation of the waiver. It looks at payment rates for children and adults, by tier, and for separately rated groups such as the categorically needy, medically needy, and disabled clients. Three types of State expenditures are compared in this paper: predicted expenditures based on actuarial projections, expenditures made on the basis of service utilization, and expenditures made after being adjusted for over payment controls. Expenditure predictions were consistently lower than actual expenditures, even after adjustments for over payment.

Financial management of posthospital care programs.

In this article the model estimates differences in utilization and subsequent costs of inpatient acute care, nursing home, and clinic visits as a result of patients using a posthospital care program. These estimates are compared to actual costs showing the models robustness. The model is developed to aid in both the evaluation and the management of hospital-based postdischarge programs.