Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income.

Combining the economic literature on principal-agent relationships with examples of marketplace innovations allows analysis of the evolution of methods for paying physicians. Agency theory and the economic principles of performance-based compensation are applied in the context of imperfect information, risk aversion, multiple interrelated tasks, and team production efficiencies. Fee-for-service and capitation are flawed methods of motivating physicians to achieve specific goals. Payment innovations that blend elements of fee-for-service, capitation, and case rates can preserve the advantages and attenuate the disadvantages of each. These innovations include capitation with fee-for-service carve-outs, department budgets with individual fee-for-service or “contact” capitation, and case rates for defined episodes of illness. The context within which payment incentives are embedded, includes such nonprice mechanisms as screening and monitoring and such organizational relationships as employment and ownership. The analysis has implications for health services research and public policy with respect to physician payment incentives.

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Theory and practice in the design of physician payment incentives.

Health Care Financing Review

Using data from a 1996/1997 survey of undocumented Latino immigrants in four sites, we examine reasons for coming to the United States, use of health care services, and participation in government programs. We find that undocumented Latinos come to this country primarily for jobs. Their ambulatory health care use is low compared with that of all Latinos and all persons nationally, and their rates of hospitalization are comparable except for hospitalization for childbirth. Almost half of married undocumented Latinos have a child who is a U.S. citizen. Excluding undocumented immigrants from receiving government-funded health care services is unlikely to reduce the level of immigration and likely to affect the well-being of children who are U.S. citizens living in immigrant households.

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Health care use among undocumented Latino immigrants

Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities).

Quantitative analysis of medical liability?s influence on medical practice is a small but growing field, noted this literature review and commentary. The three papers on defensive medicine in this journal issue illustrated three possible analytic approaches: case study of technological diffusion, survey of physician responses to detailed clinical scenarios, and multivariate analysis of relation of physicians' scenario responses to objective liability experience. The papers also offered a good picture of the state of the art: Many difficulties hamper research in this area, and these papers like others offer considerable illumination but leave much uncovered. Defensive medicine surely exists, but its impacts on health care spending and access are unclear. The most important lessons for public policy are that tort reform may be necessary but not sufficient to reduce the problems associated with defensive medicine and that the major malpractice problem continues to be malpractice. (Journal of Health Politics, Policy and Law 1996 Summer; 22(5); 1133-1189).

Defensive Medicine and Tort Reform: New Evidence in an Old Bottle

Concern about high infant mortality and morbidity in the United States, combined with the erosion of private insurance coverage, sparked major expansions in the Medicaid program in the 1980s. This study examines how the Medicaid expansions for pregnant women affected access to prenatal care for low-income women through case studies conducted in four states early in 1991. Despite the significantly greater share of births covered by Medicaid in the period 1986 to 1991, the timely initiation of prenatal care improved in only one state. Although prenatal services increased in some areas, significant problems persisted in others. The growth in capacity of the prenatal care system was greatest when state and local policies designed to increase supply were also instituted. While the Medicaid expansions eliminated significant barriers to prenatal care for low-income women, other policies that have been designed to reduce the remaining barriers may be necessary in order significantly to expand access to prenatal care and to improve birth outcomes.

Local responses to expanded Medicaid coverage for pregnant women.

This study used data from 1986 through 1992 to estimate the ?volume offset? that may occur when payment rates for Medicare physician services are changed. Although policymakers assume that 50 percent of all fee reductions are offset by volume increases and that this occurs across all type of services, this analysis does not support that position. There is a ?volume offset,? but it is generally smaller than 50 percent. For evaluation and management and imaging services, an offset of about 25 percent would seem appropriate. Although the 50 percent assumption for procedures is consistent with this study, our analysis suggests that an offset occurs in response to fee increases as well as decreases. (Medical Care Research and Review 1998 December; 55(4):457-458).

Price Controls and Medicare Spending: Assessing the Volume Offset Assumption:

The quantity and cost-effectiveness of prenatal care is a critical reproductive health issue as federal and state legislators consider reducing publicly funded services to aliens. An analysis of data from medi-Cal, California's Medicaid program, shows that undocumented and legalized aliens who qualified for coverage under the provisions of federal legislation or the state's expansion of eligibility criteria accounted for 45% of deliveries financed by Medi-Cal in 1991; outlays for these deliveries are estimated at less than 2% of all Medi-Cal payments for that year. Most of these women also received prenatal care covered by Medi-Cal, but more than half were not enrolled in the program until after the first trimester of pregnancy (and thus may not have received adequate prenatal care). Alien women were enrolled for an average of 5-6 months of their pregnancy, whereas nonalien women who qualified for coverage were enrolled for about seven months. California's Proposition 187 would eliminate funding for prenatal care for undocumented aliens, but public outlays for labor and delivery could grow as a result of an increase in poor birth outcomes.

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Medicaid coverage of maternity care for aliens in California.

This study analyzes changes in Medicaid physician fees from 1990 to 1993. Data were collected on maximum allowable Medicaid fees in 1993 and compared with similar 1990 Medicaid data as well as the fully phased-in Medicare Fee Schedule (MFS). The results suggest that, on average, Medicaid fees have grown roughly 14 percent, but considerable variation continues to exist in how well Medicaid programs pay across types of services, States, and census divisions. Medicaid fees remain considerably lower (27 percent for the average Medicaid enrollee) than fees under a fully phased-in MFS. Medicaid fees for primary-care services were, on average, 32 percent lower.

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Stephen A. Norton

Papers

Defensive Medicine and Tort Reform: New Evidence in an Old Bottle

Local responses to expanded Medicaid coverage for pregnant women.

Price Controls and Medicare Spending: Assessing the Volume Offset Assumption:

Medicaid coverage of maternity care for aliens in California.

Medicaid Fees and the Medicare Fee Schedule: An Update