Attitudes and knowledge about case mix reform among hospital staff in Australia.

This paper reports some of the findings of a national survey of staff in acute care hospitals about their knowledge of case mix and their attitudes towards it. Our findings suggest that, despite the range and scope of activities that have been pursued under the Australian Casemix Development Program (ACDP), knowledge of case mix among acute care hospital staff remains patchy. The evidence also shows that significant aspects of the DRG classification system and the uses to which it can be put are not accepted by many hospital staff, particularly medical staff. The paper concludes with a discussion of what some of these findings imply for future activity on case mix reform.     

Hospitals' marketing challenge: influencing physician behavior

Physicians' referring and admitting behavior as well as their clinical management practices are major determinants of hospitals' profitability under prospective payment. Four techniques are available to hospitals that seek to increase market share: Recruitment and retention strategies. In planning the mix of specialties represented on staff, hospitals should consider the effects of a physician's practice on the hospital's case mix. Peer pressure. Peer review programs in hospitals as well as through medical or specialty societies may help persuade physicians to alter their use of services. Education and information programs. Hospitals can assist physicians in patient management by conducting economic grand rounds, developing committees to study and communicate cost data to physicians, and providing information on alternatives to hospitalization. Incentives. Putting physicians at risk by linking planned expenditures to hospital financial performance can influence practice patterns. Other techniques include offering limited partnerships to medical staff members and merging the hospital and medical staff into one corporation. Hospitals may also need to influence physicians away from ventures that compete directly with the institution, such as ambulatory surgery centers.     

医疗保险信用等级制度对医院的约束作用分析

本文一方面分析了医疗保险信用等级制度对医院业务量和收入的影响,比较该制度实施前后医疗保险管理机构对定点医院经济约束作用的变化;另一方面分析了该制度对医院信誉认知的影响、医院员工对信用等级重要性认知和医院员工提高信用等级意愿等方面的内容,确定信用等级制度对医院社会声望方面的影响以及医疗保险机构对定点医院制约作用的变化。综合以上两个方面的分析得出结论:信用等级制度对于不同医院的服务量和业务收入以及社会声望具有显著影响,医院员工具有为使医院获取社会声望而提高信用等级的明显倾向,医疗保险管理机构对定点医院的约束作用进一步增强。     

The Composition of Rural Hospital Medical Staffs: The Influence of Hospital Neighbors

The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.     

Hospital competition, managed care, and mortality after hospitalization for medical conditions in California

OBJECTIVE: To assess the effect of hospital competition and health maintenance organization (HMO) penetration on mortality after hospitalization for six medical conditions in California. DATA SOURCE: Linked hospital discharge and vital statistics data for short-term general hospitals in California in the period 1994-1999. The study sample included adult patients hospitalized for one of the following conditions: acute myocardial infarction (N=227,446), hip fracture (N=129,944), stroke (N=237,248), gastrointestinal hemorrhage (GIH, N=216,443), congestive heart failure (CHF, N=355,613), and diabetes (N=154,837). STUDY DESIGN: The outcome variable was 30-day mortality. We estimated multivariate logistic regression models for each study condition with hospital competition, HMO penetration, hospital characteristics, and patient severity measures as explanatory variables. PRINCIPAL FINDINGS: Higher hospital competition was associated with lower 30-day mortality for three to five of the six study conditions, depending on the choice of competition measure, and this finding was robust to a variety of sensitivity analyses. Higher HMO penetration was associated with lower mortality for GIH and CHF. CONCLUSIONS: Hospitals that faced more competition and hospitals in market areas with higher HMO penetration provided higher quality of care for adult patients with medical conditions in California. Studies using linked hospital discharge and vital statistics data from other states should be conducted to determine whether these findings are generalizable.     

Regulatory intensity, hospital size and the formalization of medical staff organization in hospitals.

Using a theory of organizational response to regulation, this study examined the effects of regulatory intensity and hospital size on the formalization of medical staff organization in Canadian hospitals. The general hypothesis was that, in provinces with greater regulatory intensity, hospitals would exhibit greater formalization of medical staff, and greater involvement of physicians in hospital governance and management; larger hospitals would have greater formalization of medical staff than smaller hospitals. Data from 574 hospitals indicated that both hospital size and provincial regulatory intensity were important factors predictive of the overall formalization of medical staff organization. Depending upon the provincial location, hospitals have developed different patterns of formalizing their medical staff structures.     

公立医院产权制度改革形势与出路和探讨

公立医院产权制度改革的形势是:国有资产管理体制改革从制度上推进医院产权制度改革,合资医院、民营医院、社区卫生服务中心和药店从医疗市场竞争上促进医院产权制度改革。医院自身改革要求突破产权制度的瓶颈,国有资产流失和变相流失呼唤政府要加快产权制度改革。公立医院产权制度改革的主要出路是:确定今后政府拥有公立医院的数量,确立公立医院的管理机构,确立公立医院产权制度改革的措施。其主要措施有:建立现代医院产权制度,组建大型医疗集团,出售经营不善的公立医院,安置产权制度改革后的分流人员,鼓励保险公司和社会团体收购公立医院。     

Updated variable-radius measures of hospital competition

OBJECTIVE: To calculate variable-radius measures of hospital market size and create measures of competition for hospitals' markets. DATA SOURCES: Discharge abstracts from the 1997 State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) linked with the American Hospital Association (AHA) Annual Survey, Area Resource File (ARF), InterStudy Regional Market Analysis database, and Medicare's Prospective Payment System Impact Files. STUDY DESIGN: Hospital radii capturing 75 and 90 percent of hospital admissions regressed against hospital and health care market characteristics and other local area characteristics, where the specification was designed to maximize predictive ability. The number of competing hospitals and the Herfindahl-Hirschman index (HHI) of competition were calculated for each hospital's market. DATA COLLECTION METHODS: Discharge abstracts were used to create actual radii for hospitals in nine states. These data were linked with other data describing hospital, health care market, and other characteristics. PRINCIPAL FINDINGS: We explained 44.7 and 9.6 percent of the variation among urban and rural hospitals, respectively, in radii that capture 90 percent of patients, and slightly less of the variation in radii that capture 75 percent of patients. Population density; number of other hospitals in the local area; and hospital characteristics such as medical school affiliation, percentage of admissions that are Medicaid, case mix, and service offerings are important correlates of a hospital's market size. CONCLUSIONS: Predicted radii and associated competition measures were created (matched to AHA hospital identifiers) for all nonfederal, short-term, general medical/surgical hospitals in the continental United States for which complete data were available in 1997 (N=4,806) and are available from the authors.     

The financial performance of selected investor-owned and not-for-profit system hospitals before and after Medicare prospective payment.

This article analyzes determinants of cost and profitability, including the influence of Medicare prospective payment (PPS), between 1983 and 1985 for nearly 300 hospitals belonging to investor-owned (IO) and not-for-profit (NFP) systems. Using approaches that assure comparability of financial data, and including case mix, quality, competition, and regulation measures, the findings indicate that (1) in both years, competitive environment, case mix, age of facility, and scope of diversified services were important determinants of average cost, while a process measure of quality was insignificant and the independent effect of ownership type was insignificant for cost; (2) effects of HMO competition and hospital strategy were stronger in 1985 than in 1983; (3) operating margins for all types of hospitals showed increases, with a somewhat greater improvement for NFP system members; and (4) significantly greater declines in volume of care occurred for IO system members. Implications for future research are discussed.     

Managed Care and Organizational Influences on Hospitalist Program Adoption

Hospitalists help improve healthcare efficiency, but less is known about the factors that influence hospitals to utilize hospitalists. The purpose of this research was to investigate the influence of managed care and hospital case mix on hospitalist program adoption in general hospitals. Maximum likelihood estimation was used to estimate a nonlinear binary response model to predict hospitalist program adoption. Hospital case mix was positively and significantly associated with the adoption of a hospitalist program while health maintenance organization market share was negatively related to hospitalist program adoption. Managers may want to consider these factors when planning to adopt a hospitalist program.     

我国病例组合方案研究概述

目的：利用我国现有的病案信息,形成真正意义上的病例组合方案。方法：论述病例组合的研究背景及国内外研究和应用现状,介绍度量医疗“产出”的病例组合模式、数据来源和统计分类方法。结果：形成了军队住院病人的病例组合方案、地方住院病人的病例组合方案和门诊病人的病例组合方案,研制出能在Windows95/98操作环境下运行的医院病例组合指数的计算软件。结论：建立基于我国病案首页的病例组合方案已具备理论方法和数据条件。根据大样本数据建立的组合方案,已经可以用于医疗费用的控制、医院医疗“产出”的评价和医院经费补偿的测算。     

The effects of case mix on hospital costs and revenues in managed care environments

Due to competition and managed care, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. It is important to pay hospitals based on the expected resource use of patients that hospitals treat. However, managed care organizations pay hospitals based on negotiated prices that do not consider the expected resource use of patients. The purpose of this paper is to provide a better understanding of those factors affecting hospital cost and revenue in California using the hospital financial and utilization data for selected years from 1986 to 1998. By developing case mix indexes (CMIs) using all hospital discharges in California, this study found that the coefficients for CMIs in total and inpatient hospital revenue models were greater than those in hospital cost models. Over time, however, the differences in coefficients for CMIs in hospital revenue and cost models become smaller and smaller. Thus, this study shows that the difference between hospital revenues and hospital costs, looking at hospital case mix, has decreased, although hospital revenues are still greater than hospital costs.     

Factors and perspectives affecting nursing resource consumption in community hospitals.

The consumption of professional and non-professional nursing resources on medical/surgical nursing units varies sharply among community hospitals. In an effort to explain the variation, this study examines several factors: socio-economic characteristics of the population; supply of registered nurses; hospital characteristics such as size, complexity and diversity of services; patient characteristics such as case mix index and nursing care acuity index; and production system characteristics such as efficiency of technical support systems and the structure of nursing care delivery. Nursing skill mix varies more than the staffing levels among hospitals. The research suggests that factors associated with a clinical-rational model such as nursing acuity index and the efficiency of clinical/support systems explains little, whereas factors associated with economic-rational model of hospital revenues--like case mix, number of hospital services, poverty (through Medicaid program) and age distribution (through Medicare program)--do significantly affect nursing resource consumption. The results point to the presence of resource allocation to nursing based on hospital revenues rather than patient care needs.     

某大型军队医院人员编配方法探讨

本文在军队医院编制体制的文献回顾的基础上,确定人员编配应遵循的原则和依据;通过专家咨询法和皮尔生长曲线模型、三次指数平滑等数理统计方法,预测某大型军队医院的展开床位数、门诊量和住院人数,并结合医院不同类型卫生人员实际工作特点,测算该院人员的理论编配值。通过对该院卫生人员理论配置值和实际配置值之间的比较,分析医院各类卫生人员配置的合理程度,并对今后定编工作提出相应的建议。     

The effect of payer mix on the adoption of information technologies by hospitals

BACKGROUND: Numerous studies have examined the relationship between organization characteristics and hospital adoption of information technology (IT). However, no known study has examined whether patient characteristics of those treated at a given hospital influences the decision to adopt IT. PURPOSE: The present study combines primary and secondary data to examine the effect of payer mix (the combination of payers that make up a given hospital's patient discharges) on IT adoption in hospitals. METHODS: Survey data from Florida hospitals were combined with the state's hospital discharge database. Multiple regression analyses were used to analyze the data. RESULTS: When examining Medicare, Medicaid, traditional commercial insurance, and managed-care plans, only an increase of managed-care patients, as a percentage of hospital discharges, was associated with a significant increased likelihood to adopt clinical and administrative IT applications by hospitals. PRACTICE IMPLICATIONS: Our results suggest that increasing cost pressures associated with managed-care environments are driving hospitals' adoption of clinical and administrative IT systems as such adoption is expected to improve hospital efficiency and lower costs. Given that such cost pressures are also emergent in Medicare, Medicaid, and traditional third-party payment environments, an opportunity exists for these parties to motivate hospital IT adoption as a means for cost reduction.     

Medicare inpatient physician charges: an econometric analysis

To control Medicare physician payments, Congress in 1989 established volume performance standards (VPS) that tie future physician fee increases to the growth in expenditures per beneficiary. The VPS risk pool is nationwide, and many observers believe it is too large to affect behavior. VPS could be modified by defining a separate risk pool for inpatient physician services and placing each hospital medical staff at risk for those services. Using a national random sample of 500,000 Medicare admissions, we explore the determinants of medical staff charges and comment on the policy implications. Multivariate analysis shows that charges increase with case mix and bed size but, surprisingly, decrease with the level of teaching activity. The teaching result is explained by the substitution of residents for physicians in these hospitals.     

The effect of misclassification errors on case mix measurement

Case mix systems have been implemented for hospital reimbursement and performance measurement across Europe and North America. Case mix categorizes patients into discrete groups based on clinical information obtained from patient charts in an attempt to identify clinical or cost difference amongst these groups. The diagnosis related group (DRG) case mix system is the most common methodology, with variants adopted in many countries. External validation studies of coding quality have confirmed that widespread variability exists between originally recorded diagnoses and re-abstracted clinical information. DRG assignment errors in hospitals that share patient level cost data for the purpose of establishing cost weights affects cost weight accuracy. The purpose of this study is to estimate bias in cost weights due to measurement error of reported clinical information. DRG assignment error rates are simulated based on recent clinical re-abstraction study results. Our simulation study estimates that 47% of cost weights representing the least severe cases are over weight by 10%, while 32% of cost weights representing the most severe cases are under weight by 10%. Applying the simulated weights to a cross-section of hospitals, we find that teaching hospitals tend to be under weight. Since inaccurate cost weights challenges the ability of case mix systems to accurately reflect patient mix and may lead to potential distortions in hospital funding, bias in hospital case mix measurement highlights the role clinical data quality plays in hospital funding in countries that use DRG-type case mix systems. Quality of clinical information should be carefully considered from hospitals that contribute financial data for establishing cost weights.     

Medical staff specialty mix and hospital production.

This paper analyzes the role of medical staff characteristics in determining different dimensions of hospital output. Using a set of flexible functional form production functions, and adjusting for hospital case mix, we examine the output contribution of physicians and other inputs, and the influence that physicians in different specialties have on the productivity of other physicians, as well as on other labor and capital. We also examine the input substitution possibilities available to hospitals, and where possible, we compare our estimates to those obtained by other researchers. We find that physicians have numerous significant effects of production and conclude that physicians are an important input that should not be ignored in empirical cost and production function studies for hospitals.     

我院加强学科建设的做法

广州医学院第二附属医院为扩大市场份额，加强学科建设，其做法主要是：在实施中以人为奉，创建宽松的适合人才成长的环境；把申报基金项目作为支撑点，坚持科研与临床结合，正确处理“引进”与“创新”的关系；加强学科内涵建设，适时适量重组相关学科，使学科特色久盛不衰，促进医院整体水平不断提升。