Evaluation results from prospective drug utilization review: Medicaid demonstrations

In 1992 HCFA awarded two cooperative agreements for demonstrations of prospective drug utilization review (PDUR). Iowa tested an on-line prospective drug utilization review (OPDUR) system. Washington tested payments to pharmacists for providing non-dispensing "cognitive services" (CS). In this article the authors report on an evaluation of these demonstrations and on three assessments of retrospective drug utilization review (RDUR) interventions. The evaluation failed to detect effects of either State PDUR demonstration on the frequency of drug problems, utilization of prescription drugs and other health services, and clinical outcomes. However, the State RDUR interventions had immediate effects on prescribing physicians.

Drug use and prescribing problems in four state Medicaid programs

In this article the authors present population-level prevalence rates for 61 specific drug-related problems occurring in three State Medicaid programs (Maryland, Iowa, and Washington) from 1989 through 1996 and a fourth (Georgia) from 1994 through 1996. The findings represent the first application of a consistent drug utilization review (DUR) screener program to Medicaid data across States. The study finds major differences in DUR failure rates among the four States with the lowest rates in Georgia and the highest in Washington. Only Iowa showed any population-level reduction in DUR failure rates during the study period, however, rates for community-dwelling elderly fell in most States.

The effects of hospice coverage on Medicare expenditures

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care.

An alternative in terminal care: results of the National Hospice Study

Hospice is a program of supportive services for terminally ill patients and their families, provided either at home or in designated inpatient settings, which is purported to improve patient and family quality of life at lower cost than conventional terminal care. The National Hospice Study was a multi-site, quasi-experimental study to compare the experiences of terminal cancer patients and their families in hospices with those of similar patients and families receiving conventional terminal care. The results indicate that, although care is different in hospices, e.g. lesser utilization of aggressive interventional therapy and diagnostic testing, patients' quality of life is similar in the hospice and conventional care systems with the exception of pain and symptom control, which may be better in the inpatient hospice setting. Hospice patients are more likely to die at home and their families are satisfied with that outcome. Otherwise, no consistent superiority of family outcome was associated with the hospice approach. The cost of hospice care is less than that of conventional terminal care for patients in hospices without inpatient facilities, but the cost of hospice appears to be equivalent to conventional care for patients in hospices having beds.

Cost savings in hospice: final results of the National Hospice Study

Medicare inpatient and home care costs over the last year of life of terminal cancer patients served in two types of hospices and in conventional care (CC) were compared as a part of the National Hospice Study (NHS). Both home care (HC) and hospital-based (HB) hospice patients had lower costs in the last month of life than did CC patients. HC patients substituted home care for inpatient care, yielding cost savings for lengths of hospice stay of up to 1 year. Although HB patients added home care to relatively high levels of inpatient care, their ancillary costs per inpatient day were significantly lower than those of CC patients. Thus, HB costs over the last year of life were also somewhat less than those of CC. The size of the savings associated with hospice care is sensitive to the type of hospice and the length of stay distribution of patients served; patients served longer have significantly higher costs in the last year of life.

Patient predictors of hospice choice. Hospital versus home care programs

Research findings indicate cost savings associated with home care hospices, while hospital-based hospices can be as expensive as conventional care. Based on National Hospice Study data, this article identifies the characteristics of patients admitted to hospital-based and home care hospices in those areas of the country where a choice of hospice model was possible. Multivariate logistic regression indicates that the significant discriminating factors between the two patient populations relate to the availability of supportive care at home and the severity of nursing care problems at the time of hospice entry. Reinforcing selected pre-existing differences, an examination of prehospice had longer episodes of care than was the case for home care hospice patients.

What does hospice cost?

This paper presents the preliminary results of the economic analyses of the National Hospice Study (NHS), mandated by the United States Congress to investigate the implications of including hospice services in Medicare. Data were collected over an 18-month period from approximately 4,000 patients receiving hospice and conventional terminal care in 25 hospices and 12 conventional care sites. Subsequent analysis may lead to changes in the specific results, and some of the differences may be due to confounding variables that cannot be adjusted for. According to these data, hospital based (HB) hospice costs per day are 44 per cent higher than home care (HC) hospice costs per day ($95 versus $66, respectively). In addition, per patient hospice costs are 24 per cent more for patients enrolled in HB than in HC hospices ($5,890 versus $4,758, respectively). The proportional difference between HB and HC in cost per patient is smaller than the cost per day difference due to the shorter average HB length of stay, 62.3 days compared to 72.5 days for HC. Regarding the cost savings of hospice compared to conventional care, HC hospice costs are lower than conventional care costs regardless of length of stay. However, HB costs seem lower than conventional care costs only for patients with lengths of stay less than two months. Hospice and conventional care patients appear to differ with respect to predisposition toward intensive health care utilization. When this difference is explored more thoroughly in subsequent analyses, the estimated cost differential between hospice and conventional care may change.

Hospital payroll costs, productivity, and employment under prospective reimbursement

This paper reports preliminary findings from the National Hospital Rate-Setting Study regarding the effects of State prospective reimbursement (PR) programs on measures of payroll costs and employment in hospitals. PR effects were estimated through reduced-form equations, using American Hospital Association Annual Survey data on over 2,700 hospitals from 1969 through 1978. These tests suggest that hospitals responded to PR by lowering payroll expenditures. PR also seems to have been associated with reductions in full-time equivalent staff per adjusted inpatient day. However, tests did not confirm the hypothesis that hospitals reduce payroll per full-time equivalent staff as a result of PR.