Sidney T. Bogardus

Published reports indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians. The use of deception has important implications for physician professionalism, patient trust, and rational health policy development. If deception is as widespread as these studies suggest, there may be serious problems in the medical profession and the health care financing systems at the interface between physicians and third-party payers. Deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient.

To develop and validate a new risk adjustment index-the Burden of Illness Score for Elderly Persons (BISEP)-which integrates multiple domains, including diseases, physiologic abnormalities, and functional impairments. RESEARCH DESIGN SUBJECTS: The index was developed in a prospective cohort of 525 patients aged > or = 70 years from the medicine service of a university hospital. The index was validated in a cohort of 1246 patients aged > or = 65 years from 27 hospitals. The outcome was 1-year mortality. Five risk factors were selected from diagnosis, laboratory, and functional status axes: high-risk diagnoses, albumin < or = 3.5 mg/dL, creatinine >1.5 mg/dL, dementia, and walking impairment. The BISEP score (range 0-7) created four groups of increasing risk: group I (score 0-1), group II (2), group III (3), and group IV (> or = 4). In the development cohort, where overall mortality was 154/525 (29%), 1-year mortality rates increased significantly across each risk group, from 8% to 24%, 51%, and 74%, in groups I to IV respectively (chi(2) trend, = 0.001)--an overall 17-fold increased risk by hazard ratio. The c-statistic for the final model was 0.83. Corresponding rates in the validation cohort, where overall mortality was 488/1246 (39%), were 5%, 17%, 33%, and 61% in groups I to IV, respectively (chi(2) trend, = 0.001)-an overall 18-fold increased risk by hazard ratio. The c-statistic for the final model was 0.77. In each cohort, sequential addition of variables from different sources (eg, administrative, laboratory, and chart) substantially improved model fit and predictive accuracy. BISEP had significantly superior mortality prediction compared with five widely used measures. BISEP provides a useful new risk adjustment system for hospitalized older persons. Although index performance using different data sources has been evaluated, the full BISEP model, incorporating disease, laboratory, and functional impairment information, demonstrates the best performance.