Case-mix nursing home reimbursement: a technical “fix” for a policy inadequacy?

Most state Medicaid programs, in many cases the largest fundors of long term care, reimburse nursing homes or home health agencies on negotiated flat rates. However, several states have implemented or are planning to use reimbursement methods using case-mix indices to adjust for the different variable costs (e.g., resource utilization groups, RUGs) incurred in caring for different types of patients. Advocates contend that such methods can simultaneously help contain costs and enhance access by motivating the nursing home to keep costs below predetermined rates and mitigating providers’ reluctance to admit “heavy care” residents. The numbers of such residents putatively have increased as a result of incentives in the Prospective Payment System for hospitals to more quickly discharge sicker patients. However, the potentially negative effects of case-mix reimbursement (CMR) on quality of care have not gone unnoticed, and the costs (as yet undetermined) of mechanisms to avert these effects likely are nontrivial.

This paper examines the effects of CMR on cost (to states and nursing homes), access and quality. A preliminary review of the available evidence seems to indicate mixed results; yet, CMR obviously appeals to some Medicaid programs and representatives of the nursing home industry. We suggest that the allure of CMR may be due to a mistaken belief that, to borrow from Brandon (1990), such “tech fixes” obviate irksome negotiation on the part of policy elites.

An alternate reimbursement policy is proposed: a negotiated prepayment, based on a facility's global budget, with periodic allocations and an end of period adjustment to compensate the provider for unanticipated costs.     

Governmental Corruption and Social Change in New Zealand: Using Scenarios, 1950–2020

New Zealand has long enjoyed a reputation as a country with a corruption-free state sector, and ranks very highly on the Transparency International's Corruption Perceptions Index (meaning its corruption levels are perceived to be extremely low). However, there is prima facie evidence to suggest that this situation may be changing, not dramatically but significantly. While the state sector changes of the 1980s and early 1990s may be having some impact on this shift, it also has to be understood in the context of wider societal changes, which are probably more decisive. After some brief conceptual clarification, the article presents three scenarios sketching past (1950s/1960s), present (1990s–2006) and future (2006–2020) social and governmental conditions thought to be relevant to corruption levels.     

The history of devolution of powers to local authorities in South Africa: The shifting sands of state control

Urban waste services in Portugal have historically been provided together with other services, such as the water services. Despite the lack of discussion on this subject in the literature, some questions have been raised about the gains, in terms of efficiency, of this policy. Following a recent and robust partial nonparametric frontier model, based on order-α, we intend to evaluate the presence of economies of scope in the Portuguese waste sector. Furthermore, we also estimate the economies of scale using the traditional data envelopment analysis. The results show the absence of economies of scope between waste and water (and wastewater) services. In addition, we identify the presence of economies of scale in smaller municipalities. These outcomes might be useful for policy and decision makers in further reforms.     

State and local finance in a command economy: the case of the soviet union

Two aspects of Western public finance, the economic theory of federalism and public choice theory, have insights that, if adopted in the Soviet Union, could help improve its resource allocation to permit economic growth, mitigate the problems it has with its minorities, and aid the transition away from a centralized, Communist-Party-dominated State and society. The economic reforms proposed by Chairman Mikhail Gorbachev are briefly summarized and criticized in the context of a summary discussion of governmental decisionmaking in the Soviet Union. Lessons are identified from the U.S. historical experience that suggest certain steps to improve local government as necessary preconditions for improving Soviet economic efficiency. These are free local elections, a free local press, an independent judiciary with real authority to protect the integrity of the press and local elections, real decentralization of political power to the regions, steps toward equalization of fiscal capacity among the regions, increased citizen mobility, and adoption of actions to provide incentives for Western investment in local government capital formation. This last precondition requires a convertible currency. (To achieve a convertable currency may require other economic and political changes that are beyond the scope of this paper.) Aspects of the paper rely on information publically available through mid-1989.     

Od interventions in urban settings. II: Public-sector success with planned change

The realization that a multitude of case studies indicate a set of unique public-sector constraints that do, generally speaking, work against OD interventions need not defeat continued efforts in urban governments and agencies. A first indication that these constraints are not all-powerful is the growing number and range of OD applications in the public sector. Further, the success ratio takes on significance when the difficulty of task and hard - to - achieve goals are considered. Approximately 90 percent of the 44 case reports studied here show atleast a definite balance of positive effects. Despite this cause for some optimism, OD intervenors must anticipate numerous and real constraints, e.g., the relatively shorttime-frame and political nature of efforts in the public sector. Certainly, these constraints often redefine the intervenor's role and measures of success, and advise against direct and unreflective adaptation of private - sector intervention design stopublic agencies.     

The professional as public servant: the decision-making dilemma

Administrative decision-making is increasingly complicated today by conflicting responsibilities that pressure decision-makers in different directions. Public servants are responsible to the law, Congress, administrative superiors, the agencies in which they serve, and the public. Those public servants who are members of a profession, attempting to apply special expertise and knowledge to the solution of public problems, face a set of even more complex responsibilities, governed as they are by their own professional codes of conduct whose tenets must be melded with the other obligations of governmental decision-makers.

Conscientious governmental officials are likely to base their decisions on their responsibilities to the public, in light of moral and ethical criteria as well as professional standards (where applicable), while recognizing their accountability to their organizational superiors. Civil servants who are members of a profession frequently find themselves making extremely complex decisions for which they must accept the responsibility for the application of their professional ethics in the context of their many other obligations.

The decision-making task of professionals who are also civil servants is often, therefore, an especially difficult and painful one. Cases of deep moral conflict will occur as they try to resolve their conflicting responsibilities.     

Re‐examining the Team A‐Team B exercise

The great pretenders

Peter Schweizer: Victory: The Reagan Administration's Secret Strategy That Hastened the Collapse of the Soviet Union The Atlantic Monthly Press, New York, 1994, 284 pp., $22.00.

Insight into the Japanese‐German relationship

Carl Boyd: Hitler's Japanese Confidant: General Oshima Hiroshi and MAGIC Intelligence, 1941–1945 University Press of Kansas, Lawrence, Kan., 1993, 294 p., $25.00.

Old secrets revealed

Wilhelm F. Flicke: War Secrets in the Ether Aegean Park Press, Laguna Hills, CA, 1994, 234 pp., $36.30.