Jerry Cromwell

Physician participation in state Medicaid programs.

Medicaid requires that physicians who accept Medicaid reimbursement for treating a patient agree to accept its payment as payment in full. Policy instruments under Medicaids control are both levels of reimbursement and various administrative burdens imposed on physicians by the program. A model depicting the physicians participation decision is developed, and predictions from the comparative statics analysis are discussed. Data came from a 1975--76 survey of fee-for-service physicians. The results indicate that high fee schedules and low administrative burdens are ways to stimulate physician involvement with Medicaid patients. Results on the Medicaid policy instruments and other explanatory variables on the whole lend support to the model of physician behavior proposed earlier in the paper.

No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians

In 2001 the Centers for Medicare and Medicaid Services (CMS) allowed states to opt out of the requirement for reimbursement that a surgeon or anesthesiologist oversee the provision of anesthesia by certified registered nurse anesthetists. By 2005, fourteen states had exercised this option. An analysis of Medicare data for 1999-2005 finds no evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications. Based on our findings, we recommend that CMS allow certified registered nurse anesthetists in every state to work without the supervision of a surgeon or anesthesiologist.

Pay for performance in health care: Methods and approaches

document when you quote from it. You must not sell the document or make a profit from reproducing it. Chapter 4 Concerns about quality of care have accelerated since the 1990s, as studies by Wennberg, Fisher, and others have documented large and unexplained variations in rates of health care utilization and clinical outcomes across geographic areas, calling into question the traditional approach of relying on the medical profession to deliver high-quality care uniformly (Davis & Guterman, 2007; Wennberg et al., 2002). Since about 2000, several landmark publications have highlighted widespread problems with patient safety and quality of care, most notably from the Institute of Medicine (IOM) and the These studies helped to galvanize a policy consensus, leading the federal government and private health insurance plans to increasingly focus policy, regulatory, and management interventions more directly on quality of care measurement, quality improvement programs, and financial incentives for quality improvement through pay for performance (P4P). P4P programs have focused primarily on quality of care measures to assess provider performance. Although other performance evaluation approaches, such as efficiency measures, are possible for P4P, those in policy circles currently perceive the lack of incentives for improved quality in the prevailing fee-for-service (FFS) payment systems as a major problem in the US health care system. As a result, P4P programs have focused mainly on addressing this problem. This chapter reviews issues regarding the application of quality measures in P4P programs. The first section of the chapter provides background, including conceptual frameworks for quality of care, and reviews organizations that develop and certify quality measures. The second section discusses different types of quality measures, including structure, process, and outcome measures (Donabedian, 1966). The third section reviews issues in selecting quality measures for P4P programs. The fourth section describes methods for 100 Chapter 4 analyzing quality measures for P4P. The fifth section discusses public reporting of quality measures and how that separate approach to quality improvement can be integrated with P4P programs.

Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries.

Objective:The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients. Design:A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 2 years postdischarge. Setting:The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care. Patients/Participants:Participants included all 700,000 age 65+ Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997. Measurements and Main Results:Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure. Conclusions:Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide “failures to refer” and patient “aversions to surgery” as explanations for lower black rates of surgical interventions.

Sources of hospital cost variation by urban-rural location:

Under current law, Medicares Prospective Payment System (PPS) recognizes a 25% differential in standardized average costs per admission between rural and urban areas. Using Medicare Part A and B claims data from four states across the country, this paper employs descriptive and multivariate techniques to explain the underlying sources of cost variation. DRG mix and within-DRG severity differences were found to contribute only 10-15% to the overall urban-rural variation compared to about one third for wage differences. Differences in procedure intensity for basically similar patients explained another 25-50% of the urban-rural difference depending on illness. Evidence was also found for systematic cost and procedure differences between core city versus suburban hospitals. If the urban-rural rate differential were eliminated, the impact on urban hospitals could have major effects on the intensive way in which physicians treat patients. Whether this would have demonstrable outcome effects is unknown, but initial severity differences alone do not justify the observed procedural differences.

A profile of emergency physicians 1984–1985: Demographic characteristics, practice patterns, and income

Emergency physicians (EPs) were profiled using data from a recent national survey of physicians. In addition, we compared EPs to other physicians on demographic and practice characteristics. EPs were younger than physicians in other specialties and were less likely to be foreign medical graduates or board certified. EPs were far more likely to be employed by hospitals and on salary. Their net income averaged

Anesthesia Providers: The Author Replies

93,000 in 1983, although hospital employees had lower average incomes (

Specialty Versus Community Hospitals: Referrals, Quality, And Community Benefits

83,000) than did those employed by a corporation or self-employed in a group practice (

Private physicians and public programs

101,000). Compared to other specialties, their average income was higher than nonsurgeons, but still far below surgeons. While EPs and other physicians spent about 50 to 51 hours per week in medical activities, EPs saw more patients per hour. EPs saw more uninsured individuals. These results have implications for patient access, entrepreneurism in the specialty, and credentialing.

Determining the Cost-Effectiveness Of a Computer-Based Smoking Cessation Intervention in Primary Care

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