Brant Fries recently shuffled through some papers on his desk in an effort to clean up and suddenly found himself face to face with his past.
The University of Michigan School of Public Health professor eyed an old math textbook, full of equations and formulas. "Can you believe this is what I used to do?" he asks a colleague.
Fries, the son of a magician, has made an unlikely career out of his academic background-a little like pulling a rabbit out of a hat. He majored in mathematics as an undergraduate and earned a doctorate in operations research, which involves applying quantitative techniques to solve decision-making problems.
After a fellowship at New York's Columbia University in which he applied operation research to healthcare delivery, Fries applied his background to long-term care and helped develop a Medicare and Medicaid prospective payment system used to pay nursing homes in nearly two dozen states.
Some current projects for Fries include: studying a case-mix system for psychiatric hospitals, which is likely to be incorporated into the Medicare prospective payment system; implementing an assessment tool for nursing home residents in Louisiana by using algorithms to define the level of care needed; and working with the Michigan Department of Community Health on developing methods to determine which elderly patients in the state qualify for Medicaid long-term-care assistance.
Fries says he's not thrilled with the motive for the Michigan project-which is expected to be rolled out within a year-because the state is looking to save money and this will ultimately mean fewer people will qualify for the funds. Currently, the state uses mostly physician referrals, but Fries says his system will help determine which residents are most in need of the program.
Along with teaching at Michigan, he's also president of an international consortium for long-term-care researchers. Fries says he became one of the world's leading experts on long-term care without setting out to do so.
Rolling out the RUGs
More than 25 years ago, Fries developed a concept that became known as resource utilization groups, or RUGs-a case-mix system for nursing home residents-while working as an associate professor at Yale University. A few years later, Fries says he didn't see himself advancing at Yale but was asked to head the University of Michigan's new long-term-care program.
Fries says he was shocked when the offer was extended to him. "I literally turned around," he says, because he thought the offer was being made to someone else. However, after thinking about it, Fries says he could name only about a half-dozen people in the U.S. who were full-time researchers focusing on long-term care. "I didn't think I was even one of them," he says.
Fries agreed to take the post "but only for five years." Nearly 20 years later, he's still at Michigan and has become world-renowned for his achievements in the long-term- care field.
In the long-term-care segment of the healthcare industry, Fries is best-known for developing RUGs. Fries recalls that he was assigned the task of assessing cost in long-term care while he was a "very junior professor at Yale."
One day he and other professors were preparing for a meeting when "A senior professor comes in and says, `We need to develop a proposal on how to assess cost in long-term care,' " Fries says. "We were all hiding under the table. The senior professor pointed at me and said, `Fries, you don't have enough to do. You do it.' "
Assessing long-term-care issues is a complex task, he says.
"For acute-care hospitals it's very easy. You just look at length of stay," he says. "But at nursing homes, it's much more difficult to do that because you often stay until you die."
What Fries developed was a system that examined the intensity of care provided. He used information gathered from rigorous research into how nursing homes provided care to develop algorithms that place individuals into categories reflecting the relative costs of services they are likely to consume. Now RUGs are used for Medicare and Medicaid payments for nursing homes in about 20 states, with more planning to adopt the system.
"(RUGs are) the watershed in long-term care, (similar) to what DRGs are in acute care," says John Morris, co-director of the Research and Training Institute of the Hebrew Rehabilitation Center for Aged, Boston, and a longtime colleague of Fries.
Before RUGs, Fries says nursing homes were mostly given per-patient reimbursements. Under that system it was more lucrative for nursing facilities to care for the patients who needed the least amount of resources, he says.
Barbara Gay, director of information for the American Association of Homes and Services for the Aging, says the RUGs system, which went into effect for Medicare under the Balanced Budget Act of 1997, was put in as a cost savings for the government, the expectation being that facilities would keep costs down by providing fewer services.
However, Gay says payments have been pretty much in line with costs, with the one main exception being that there's no provision for outliers-patients who need the most care. The government has given add-on payments to offset some of those costs, she says.
Assessing the need
For Fries, the next logical step after a case-mix classification system was developing a tool for understanding how to improve care for residents. That led him and others to develop residential assessment instruments, or RAIs.
RAIs are basically a formula that suggests to long-term-care workers what types of care residents will need depending on the patients' condition. They can be used to assess the health and needs of individuals in nursing homes or post-acute-care units in skilled-nursing facilities.
In the late 1980s, HCFA (now the CMS) contracted with researchers-including Fries-to develop a long-term-care RAI. A national RAI is now used at nursing homes to measure quality, develop quality norms and evaluate regulations and payment incentives.
While developing these tools, Fries started to hear from peers in other countries who were struggling with many of the same problems. This prompted Fries, along with Morris, to establish InterRAI, a not-for-profit corporation composed of a network of researchers from 21 nations. Fries has been president of the organization for the past 15 years.
Through this project, Fries says he's been able to compile "a lifetime of data," and it's helped long-term-care experts around the globe collaborate on solutions to common challenges. Morris says versions of Fries' RUGs and RAIs are being used in 25 countries, including Canada, Hong Kong, Iceland, Italy and Switzerland.
Working with InterRAI has not only helped Fries learn about international healthcare trends and benchmarking, but it's also taught him how cultural differences can be factored into healthcare problems, he says. He described one conference call in which stressors-events that could lead to high anxiety or stress in patients-were the topic of conversation.
"A colleague from Spain said there is no listing for death of a cow," Fries says, a comment intended to make the point that people in rural settings or in poor nations have much different stressors than people in urban environments.
Morris adds that Fries has a "head full of funny stories" and he always seems to break the ice with a humorous anecdote or joke. "He'll pick a `Far Side' cartoon or whatever. It's amazing," Morris says.
On a rare occasion, Fries will also break out a magic trick. Fries' father, Joseph, was a physician in New York and a president of the Society of American Magicians. One of his father's sponsors for membership in the society was the legendary Harry Houdini.
Similar to Houdini, Fries tries to escape questions about his magic-and also about his fencing skills. Fries, who rarely competes now, recently recorded a .500 record against the Michigan intramural fencing team, but while he was at Columbia, Fries was nationally ranked.
"That was a long time ago," he says.
Birthplace: Brooklyn, N.Y.
Family status: Late wife, Marilyn Sibley Fries; wife, Max Gibson; four adult daughters
Education: Bachelor of arts in mathematics, Columbia College, New York, 1967; master of science in operations research, Cornell University, Ithaca, N.Y., 1971; Ph.D. in operations research, Cornell, 1972
Previous jobs: Associate professor, School of Management at Rensselaer Polytechnic Institute, Troy, N.Y., 1982-85; associate professor, School of Organization and Management at Yale University, New Haven, Conn., 1978-82; assistant professor, School of Public Health at Columbia University, New York, 1973-78; instructor, School of Engineering, Cornell, 1969-71