1 Dartmouth Hitchcock Medical Center, Lebanon, NH; 2 Dartmouth College, Hanover, NH PURPOSE: One large for-profit hospital chain has admitted to inflating the severity of discharge diagnoses (``upcoding'') for economic gain. It is unknown how widespread this practice is, or whether it is endemic to for-profit hospitals. We examined the association between for-profit hospital ownership and upcoding for Medicare discharges for pneumonia, the most widely recognized condition under which upcoding seems to occur. METHODS: To analyze time trends in coding patterns, we used a 20 percent national sample of Medicare inpatient claims for 1989 through 1997 with the hospital as the unit of analysis. Hospital ownership was defined as for-profit, not-for-profit, or government based on the American Hospital Association's Annual Survey of Hospitals for each year. The relevant diagnosis related groups (DRGs) were for simple pneumonia with and without complications (DRGs 89 and 90), and for complex pneumonia with and without complications (DRGs 79 and 80). The dollar reimbursement for complex pneumonia is approximately 50 percent higher than for simple pneumonia. For each year and ownership group we calculated an upcoding ratio defined as the percentage of disharges coded for complex pneumonia out of the total discharges for simple and complex pneumonia combined. RESULTS: Crude upcoding ratios for pneumonia were highest among for-profit hospitals for each year between 1989 and 1997. In addition, between 1989 and 1996, the upcoding ratio increased from 0.20 to 0.30 in not-for-profit hospitals, 0.21 to 0.30 in government hospitals, and from 0.28 to 0.51 in for-profit hospitals. Between 1996 and 1997 the ratio fell slightly for each group, which corresponds to a period of great publicity and legal charges of fraud. Average thirty-day mortality rates for the DRGs under consideration were similar across ownership categories, and in fact declined over the study period, suggesting that differences in the percentage of pneumonia discharges coded as complex was not related to case-mix. CONCLUSION: For-profit hospital ownership was associated with higher upcoding ratios among Medicare discharges for pneumonia than in not-for-profit hospitals. PURPOSE: Physicians' attitudes are important because of the possible impact they may have on the structure and quality of patient care [1] . In 1982 Mathews et al [2] , surveyed San Diego County Medical Society's physicians about their attitudes toward homosexuality. They found significant differences in prevalence of homophobic attitudes by gender, year of medical school graduation, specialty and practice setting [2] . Our objective was to assess physicians' attitudes toward homosexuality and toward persons with HIV infection and to compare the current prevalence of homophobia to that measured seventeen years previously. METHODS: An anonymous, self-administered, 17-item survey was mailed to all 4,385 members of the SDCMS and 1,271 UCSD physicians. The survey included 8 likert-scaled items measuring general attitudes toward homosexuality (Cronbach's alpha = 0.88). Additional items assessed attitudes toward entry to medical school and consultative referral patterns, conditional on sexual orientation and HIV status of hypothetical referents. PURPOSE: Somatization is a common costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment. We tested an hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed`s omatization potential,'' the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints. METHODS: We identified high utilizing patients from the MIS of a large staff model HMO as those having 6 or more visits during the year studied (65th percentile). A physician rater then reviewed the medical records of these patients and identified somatizing and nonsomatizing patients. In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians [ICD-9 codes]. We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its utility. RESULTS: The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic was .90. In the validation set, the explanatory power was less with a c-statistic of .78. A predicted probability of .04 identified almost all somatizers, while a predicted probability of .40 identified about half of all somatizers but produced few false positives. CONCLUSION: We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians' time. PURPOSE: High utilizing patients with medically unexplained symptoms often are believed to be somatizing patients, defined here as no organic disease explanation for symptoms of at least 6 months duration. High utilizing patients with unexplained symptoms of shorter duration have not been studied and there is no effective treatment for this group, which we call``minor acute illness.'' METHODS: Our aim was to determine how many high utilizing patients with medically unexplained symptoms met our chart-rating criteria for somatization and or minor acute illness and what the stability of these diagnoses was over time. We performed chart review at baseline; one and two years later, we re-rated the charts of patients initially rated as having somatization as well as a 15% sample of those with minor acute illness. Subjects were a random sample of high utilizing staff model HMO patients (6 or more visits/year) from 21 ± 55 years old, identified from the management information system (MIS). Chart review designations as organic disease, somatization, or minor acute illness were the measurements made. RESULTS: Among 883 high utilizing patients, 35% had organic diseases, 14% had somatization, and 51% had minor acute illness as their primary problems. No patients with initial minor acute diagnoses were reclassified as somatization one and two years later and all but 2 patients had minor acute illness in one or both follow-up years. Among somatizers, 54% were re-classified as minor acute illness the following year and, of these, 50% remained as minor acute illness in the second follow-up year. 70% of initial somatizers and 45% of initial minor acute patients continued to be high utilizers in one or both follow-up years. Persistent high utilization in both follow-up years occurred in 17% of minor acute patients and33% of somatizing patients. CONCLUSION: Minor acute illness appears more common among high utilizing patients than somatization and organic diseases combined. It has not previously been studied. Diagnoses of somatization were unstable over two years follow-up while minor acute diagnoses were stable, supporting the latter as a valid entity. Utilization did not remain high in either group. We recommend further study of minor acute illness to determine its relationship to somatization, to determine if it is a valid entity, and to better understand the broad spectrum of patients with medically unexplained symptoms.