The Impact of the Inpatient Prospective Payment System and Diagnosis-Related Groups: A Survey of the Literature

North American Actuarial Journal

Volumn 5, Issue 4, 2001, Pages 84-94

  Rosenberg, Marjorie A ^a   Browne, Mark J ^a  

^a UNIVERSITY OF WISCONSIN MADISON   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 85011229293     PISSN: 10920277     EISSN: None     Source Type: Journal    
DOI: 10.1080/10920277.2001.10596020     Document Type: Article

References (75)

1. BRAY, N., C. CARTER, A. DOBSON, J. M. WATT, and S. SHORTELL. 1994. "An Examination of Winners and Losers under Medicare's Prospective Payment System," Health Care Management Review 19(1): 44-55.
2. CARTER, G., P. JACOBSON, G. KOMINSKI, and M. PERRY. 1994. "Use of Diagnosis-Related Groups by Non-Medicare Payers," Health Care Financing Review 16(2): 127-58.
3. CARTER, G., J. NEWHOUSE, and D. RELLES. 1990. "How Much Change in the Case Mix Index Is DRG Creep?" R-3826-HCFA. Santa Monica, CA: RAND Corporation.
4. CARTER, G., J. NEWHOUSE, and D. RELLES. 1991. "Has DRG Creep Crept Up? Decomposing the Case Mix Index Change between 1987 and 1988." R-4098-HCFA/ProPAC. Santa Monica, CA: RAND Corporation.
5. DESHARNAIS, S., E. KOBRINSKI, J. CHESNEY, M. LONG, R. AMENT, and S. FLEMING. 1987. "The Early Effects of the Prospective Payment System on Inpatient Utilization and the Quality of Care," Inquiry (spring) 24: 7-16.
6. DRANOVE, D. 1987. "Rate-Setting by Diagnosis Related Groups and Hospital Specialization," RAND Journal of Economics 12(3).
7. DRANOVE, D. 1988. "Pricing by Non-profit Institutions: The Case of Hospital Cost-Shifting," Journal of Health Economics 7: 47-57.
8. FARLEY, D., and C. HOGAN. 1990. "Specialization in the Market for Hospital Services," Health Services Research 25(6): 757-81.
9. FEIGENBAUM, S., G. ANDERSON, and J. LAVE. 1992. "Medicare's Prospective Payment System: The Victim of Aggregation Bias?" Review of Economics and Statistics 74(1): 185-91.
10. FETTER, R., D. BRAND, and D. GAMACHE. 1991. DRGs: Their Design and Development. Ann Arbor, MI: Health Administration Press.
11. FETTER, R., Y. SHIN, J. FREEMAN, R. AVERILL, and J. THOMPSON. 1980. "Case Mix Definition by Diagnosis-Related Groups," Medical Care 18(Suppl.): 1-53.
12. FISHER, C. 1992. "Hospital and Medicare Financial Performance under PPS, 1985-90," Health Care Financing Review 14(1): 171-83.
13. FISHER, E. S., F. S. WHALEY, W. M. KRUSHAT, D. J. MALENDA, D. FLEMING, J. A. BARON, and D. C. HSIA. 1992. "The Accuracy of Medicare's Hospital Claims Data: Progress Has Been Made, but Problems Remain," American Journal of Public Health 82(2): 243-48.
14. FISHER, M. 1997. "HCFA Audit Shows $23B in Overpayments," National Underwriter Life/Health (Aug. 4): 28.
15. FOSTER, R. 1985. "Cost-Shifting under Cost Reimbursement and Prospective Payment," Journal of Health Economics 4: 261-71.
16. FRIEDMAN, B., and D. FARLEY. 1995. "Strategic Responses by Hospitals to Increased Financial Risk in the 1980s," Health Services Research 30(3): 467-88.
17. GOLDFARB, M., and R. COFFEY. 1992. "Change in the Medicare Case-Mix Index in the 1980s and the Effect of the Prospective Payment System," Health Services Research 27(3): 385-415.
18. GRANNENMANN, T., R. BROWN, and M. PAULY. 1986. "Estimating Hospital Costs: A Multiple-Output Analysis," Journal of Health Economics 5: 107-27.
19. GUNDLING, R. 2000. "OIG Audit of HCFA Prompts Steps to Reduce Payment Errors," Health-Care Financial Management 54(5): 90-1.
20. GUTERMAN, S., and A. DOBSON. 1986. "The Impact of the Medicare Prospective Payment System for Hospitals," Health Care Financing Review 7(2): 97-114.
21. GUTERMAN, S., P. EGGERS, G. RILEY, T. GREENE, and S. TERRELL. 1988. "The First 3 Years of Medicare Prospective Payment: An Overview," Health Care Financing Review 9(3): 67-77.
22. GUTERMAN, S. 1998. "The Balanced Budget Act of 1997: Will Hospitals Take a Hit on their PPS Margins?" Health Affairs 17(1): 159-66.
23. HADLEY, J., and K. SWARTZ. 1989. "The Impact on Hospital Costs between 1980 and 1984 of Hospital Rate Regulation, Competition, and Changes in Health Insurance Coverage," Inquiry (spring) 26: 35-47.
24. HAY, J. 1983. "The Impact of Public Health Care Financing Policies on Private-Sector Hospital Costs," Journal of Health Politics, Policy and Law 7(4): 945-52.
25. HCFA. 2001a. "Overview of Outpatient Prospective Payment System." Online at http://www.hcfa.gov/medlearn/refopps.htm (in oppchap1.doc page 3).
26. HCFA. 2001b. "Table 5: Hospital Care Expenditures Aggregate and Per Capita Amounts and Percent Distribution, by Source of Funds: Selected Calendar Years 1960-99." Online at http//www.hcfa.gov/stats/nhe-oact/tables/t5.htm.
27. HCFA. 2001c. "Table 1: National Health Expenditures Aggregate and Per Capita Amounts, Percent Distribution, and Average Annual Percent Growth by Source of Funds: Selected Calendar Years 1960-99." Online at http://www.hcfa.gov/stats/nhe-oact/tables/t1.htm.
28. HCFA. 2001d. "1998 Data Compendium Annual Compilation of National Health Care Data." Online at http://www.hcfa.gov/stats/98datacmp.pdf.
29. HCFA. 2001e. "Statement of Robert A. Berenson, M.D., on the 'False Claims Act' before the Subcommittee on Immigration and Claims House Judiciary Committee, April 28, 1998." Online at http://www.hcfa.gov/testmony/1998/98_0428.htm.
30. HCFA. 2001f. Federal Register, Vol. 65, no. 88, Part 412, Office of the Federal Register, National Archives and Records Administration. Washington, DC: U.S. Government Printing Office.
31. HSIA, D. C., C. A. AHERN, B. P. RITCHIE, L. M. MOSCOE, and W. M. KRUSHAT. 1992. "Medicare Reimbursement Accuracy under the Prospective Payment System, 1985 to 1988," Journal of the American Medical Association 268(7): 896-99.
32. HSIA, D. C., W. M. KRUSHAT, A. B. FAGAN, J. A. TEBBUTT, and R. P. KUSSEROW. 1988. "Accuracy of Diagnostic Coding for Medicare Patients under the Prospective Payment System," New England Journal of Medicine 318(6): 352-55.
33. IEZZONI, L. 1997. Risk Adjustment for Measuring Healthcare Outcomes. 2nd ed. Chicago: Health Administration Press.
34. IEZZONI, L., and M. MOSKOWITZ. 1986. "Clinical Overlap among Medical Diagnosis-Related Groups," Journal of American Medical Association 255: 927-29.
35. KAHN, K., E. KEELER, M. SHERWOOD, W. ROGERS, D. DRAPER, S. BENTOW, E. REINISCH, L. RUBENSTEIN, J. KOSECOFF, and R. BROOK. 1990. "Comparing Outcomes of Care before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264(15): 1984-88.
36. KAHN, K., W. ROGERS, L. RUBENSTEIN, M. SHERWOOD, E. REINISCH, E. KEELER, D. DRAPER, J. KOSECOFF, and R. BROOK. 1990. "Measuring Quality of Care with Explicit Process Criteria before and after Implementation of the DRG-Based Prospective Payment System," Journal of the American Medical Association 264(15): 1969-73.
37. KAHN, K., L. RUBENSTEIN, D. DRAPER, J. KOSECOFF, W. ROGERS, E. KEELER, and R. BROOK. 1990. "The Effects of the DRG-Based Prospective System on Quality of Care for Hospitalized Medicare Patients: An Introduction to the Series," Journal of the American Medical Association 264(15): 1953-55.
38. KEELER, E., K. KAHN, D. DRAPER, M. SHERWOOD, L. RUBENSTEIN, E. REINISCH, J. KOSECOFF, and R. BROOK. 1990. "Changes in Sickness at Admission Following the Introduction of the Prospective Payment System," Journal of the American Medical Association 264(15): 1962-68.
39. KOSECOFF, J., K. KAHN, W. ROGERS, E. REINISCH, M. SHERWOOD, L. RUBENSTEIN, D. DRAPER, C. ROTH, C. CHEW, and R. BROOK. 1990. "Prospective Payment System and Impairment at Discharge: The 'Quicker-and-Sicker' Story Revisited," Journal of the American Medical Association 264(15): 1980-83.
40. LAVE, J. 1984. "Hospital Reimbursement under Medicare," Milbank Memorial Fund Quarterly 62(2): 251-68.
41. LLOYD, S. S., and J. P. RISSING. 1985. "Physician and Coding Errors in Patient Records," Journal of American Medical Association 254(10): 1330-36.
42. MANTON, K., M. WOODBURY, J. VERTREES, and E. STALLARD. 1993. "Use of Medicare Services before and after Introduction of the Prospective Payment System," Health Services Research 28(3): 269-92.
43. MCCARTHY, C. 1988. "DRGs-Five Years Later," New England Journal of Medicine 318(25): 1683-86.
44. MCMAHON, L., and H. SMITS. 1986. "Can Medicare Prospective Payment System Survive the ICD-9-CM Disease Classification System," Annals of Internal Medicine 104: 562-66.
45. MEUX, E., S. STITH, and A. ZACH. 1990. Report of Results from the OSHPD Reabstracting Project: An Evaluation of the Reliability of Selected Patient Discharge Data, July through December 1988. Sacramento, CA: Office of Statewide Health Planning and Development.
46. MEYER, J., W. JOHNSON and S. SULLIVAN. 1983. Passing the Health Care Buck: Who Pays the Hidden Cost? Washington, D.C.: American Enterprise Institute.
47. MORGAN, D. 2000. "More Health Plans Quit Medicare," Washington Post (June 30).
48. MULLER, A. 1993. "Medicare Prospective Payment Reforms and Hospital Utilization: Temporary or Lasting Effects?" Medical Care 31(4): 296-308.
49. NEWHOUSE, J. 1970. "Toward a Theory of Nonprofit Institutions: An Economic Model of a Hospital," American Economic Review 60(1): 64-74.
50. PAULY, M., and M. REDISCH. 1973. "The Not-for-Profit Hospital as a Physician's Cooperative," American Economic Review 63(1): 87-99.
51. PHELPS, C. 1997. Health Economics. 2nd ed. New York: Addison-Wesley.
52. ROCK, R. 1985. "Assuring Quality of Care under DRG-Based Prospective Payment," Medical Decision Making 5(1): 31-34.
53. ROSENBERG, M., D. FRYBACK, and D. KATZ. 2000. "A Statistical System to Detect DRG Upcoding," Health Services and Outcomes Research Methodology 1(3-4) 233-52.
54. ROVNER, J. 2001. "Providers 'Downcoding' Medicare Claims to Avert Investigation," Reuters Health Information. Online at http://www.medscape.com/reuters/prof/2000/06/06.01/20000601legi001.html.
55. RUBENSTEIN, L., K. KAHN, E. REINISCH, M. SHERWOOD, W. ROGERS, C. KARNBERG, D. DRAPER, and R. BROOK. 1990. "Changes in Quality of Care for Five Diseases Measured by Implicit Review, 1981-1986," Journal of the American Medical Association 264(15): 1974-9.
56. RUSSELL, L., and C. MANNING. 1998. "The Effect of Prospective Payment on Medicare Expenditures," New England Journal of Medicine 320(7): 439-44.
57. SCHLEFFLER, R. 1988. "The Impact of Medicare's Prospective Payment System and Private Sector Initiatives: Blue Cross Experience, 1980-1986." Final report under HCFA Grant #15-D-98757/5-01 (July).
58. SCHWEIKER, R. 1982. "Report to Congress: Hospital Prospective Payment for Medicare." U.S. Department of Health and Human Services. Washington, DC: U.S. Government Printing Office.
59. SHEINGOLD, S. H. 1986. "Unintended Results of Medicare's National Prospective Payment Rates," Health Affairs 5(4): 5-21.
60. SHEINGOLD, S. H. 1989. "The First Three Years of PPS: Impact on Medicare Costs," Health Affairs 8(3): 191-204.
61. SHEINGOLD, S., and E. RICHTER. 1992. "Are PPS Payments Adequate? Issues for Updating and Assessing Rates," Health Care Financing Review 14(2): 165-75.
62. SHWARTZ, M., and M. LENARD. 1994. "Improving Economic Incentives in Hospital Prospective Payment Systems through Equilibrium Pricing," Management Science 40(6): 774-87.
63. SIMBORG, D. W. 1981. "DRG Creep: A New Hospital-Acquired Disease," New England Journal of Medicine 304(26): 1602-4.
64. SLOAN, F., and E. BECKER. 1984. "Cross-subsidies and Payment for Hospital Care," Journal of Health Politics, Policy and Law 8(4): 660-85.
65. SLOAN, F., M. MORRISEY, and J. VALVONA. 1988. "Effects of the Medicare Prospective Payment System on Hospital Cost Containment: An Early Appraisal," Milbank Quarterly 66(2): 191-220.
66. THORPE, K. 1987. "The Distributional Implications of Using Relative Prices in DRG Payment Systems," Inquiry 24 (spring): 85-95.
67. U.S. DEPT. OF HEALTH and HUMAN SERVICES. 1998. "The Clinton Administration's Comprehensive Strategy to Fight Health Care Fraud, Waste and Abuse." Washington, DC: HHS Press Office.
68. U.S. DEPT. OF HEALTH and HUMAN SERVICES. 1999a. "Medicare: Program Safeguard Activities Expand, but Results Difficult to Measure." Washington, DC: HHS Press Office.
69. U.S. DEPT. OF HEALTH and HUMAN SERVICES. 1999b. "Medicare Fraud and Abuse: DOJ's Implementation of False Claims Act Guidance in National Initiatives Varies." Washington, DC: HHS Press Office.
70. U.S. PROSPECTIVE PAYMENT ASSESSMENT COMMISSION (PROPAC). 1990. "Medicare Prospective Payment and the American Health Care Systems: Report to the Congress." Washington, DC: U.S. Government Printing Office.
71. U.S. PROSPECTIVE PAYMENT ASSESSMENT COMMISSION (PROPAC). 1991. "Annual Report to Congress." Washington, DC: U.S. Government Printing Office.
72. VLADECK, B. 1984. "Medicare Hospital Payment by Diagnosis-Related Groups," Annals of Internal Medicine 100: 576-91.
73. VLADECK, B. 1985. "Reforming Medicare Provider Payment," Journal of Health Politics, Policy and Law 10(3): 513-32.
74. WILLIAMS, S. 1985. "The Impact of DRG-Based Prospective Payment on Clinical Decision Making," Medical Decision Making 5(1): 23-29.
75. ZUCKERMAN, S. 1987. "Commercial Insurers and All-Payer Regulation," Journal of Health Economics 6(3): 165-87.