Zinn Jacqueline S, Mor Vincent, Intrator Orna, Feng Zhanlian, Angelelli Joseph, Davis Jullet A
Temple University, Philadelphia, PA 19122, USA.
Health Serv Res. 2003 Dec;38(6 Pt 1):1467-85. doi: 10.1111/j.1475-6773.2003.00188.x.
To examine skilled nursing facilities (SNFs) "make-or-buy" decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs.
Longitudinal On-line Survey Certification and Reporting (OSCAR) data (1992-2001) on a sample of 10,241 freestanding urban SNFs.
We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided).
Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For-profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in-house.
The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.
研究20世纪90年代熟练护理机构（SNFs）在医疗保险对SNFs实施前瞻性支付系统（PPS）之前和之后，在提供康复治疗服务方面的“自制或外购”决策。
对10241家独立城市SNFs样本的纵向在线调查认证与报告（OSCAR）数据（1992 - 2001年）。
我们估计了一个基于交易成本经济理论的纵向多项逻辑回归模型，以预测四个服务提供类别（全部雇佣员工、全部外包、混合、不提供服务）中每种结果的概率。
交易频率、不确定性和复杂性导致通过雇佣而非外部承包对治疗服务有更大的控制权。营利性地位和连锁关系与对治疗服务有更大控制权相关。在PPS实施后，疗养院要么退出康复市场，要么通过内部管理康复服务对治疗服务施加更大控制，以限制交易成本。
与报销方法变化相关的财务激励措施的影响超出了直接受影响的医疗行业领域的范围。医疗保险计划需要仔细监测意外的质量和可及性后果。
