Showing papers by "Urban Institute published in 1990"

Effects of tort reforms and other factors on medical malpractice insurance premiums.

Abstract: We use state-level data on physician malpractice premiums, claims, and awards, provided by insurance companies for the years 1974 to 1986, to evaluate the effectiveness of the various tort reforms that have been legislated during the 1970s and 1980s. In addition to the tort reforms, our analysis of premiums considers insurers' anticipated losses, returns on investments, the type of insurer, and premium regulation. Our results suggest that the only reforms that significantly lower premiums are those that either impose a cap on the amount of physician liability or reduce the amount of time a plaintiff has to initiate a claim. We also find that premiums are lower when states regulate rates by requiring prior approval of premiums. In addition, it appears that the observed cyclicality in premiums is due, in part, to fluctuations in the real interest rates available to insurers as returns on investments. Unfortunately, we did not find as strong a link between the determinants of premiums, claims, and awards as might be expected.

The underclass: definition and measurement.

Abstract: The term "underclass" has been widely used by journalists and by some social scientists but, until recently, has not been clearly defined or quantified. Most of the recent quantitatively oriented literature on the topic has used a definition that emphasizes either the persistence ofpoverty or the number ofpeople living in neighborhoods where the incidence ofpoverty or dysfunctional behavior is high. Conclusions about the size and growth of the underclass are sensitive to the definition chosen, but most available evidence suggests that it is small but growing.

Determinants of transitory and permanent nursing home admissions.

Abstract: This article describes an analysis of data from the 1982-84 National Long-Term Care Demonstration Project to estimate the risks of any nursing home admission, a temporary or transitory admission, and a permanent admission. Using a multinomial logit model, the relative predictive power of several individual characteristics on nursing home use and admission type were evaluated. It was found that the cognitively impaired subgroup was at the greatest risk of entering a nursing home, especially on a permanent basis. The results also demonstrated that the combination of cognitive impairment and functional impairment further increased the risk of a nursing home admission, particularly a permanent one. Other subgroups that had high probabilities of experiencing a nursing home admission were whites, nonhomeowners, those living alone, and those with prior nursing home stays. The findings identified several aged subgroups that were at no greater risk of nursing home admission regardless of admission type: older persons who were unmarried, had a low income, had no assets, and those on Medicaid.

Toward new typologies for HMOs.

Abstract: The evolution of health maintenance organizations (HMOs) has entailed changes in both their structural characteristics and incentives to attract physicians' participation. Previous classifications of HMOs have failed to capture explicitly key features of these changes. Two alternative typologies based on incentives or organizational structures may be constructed by examining precise forms of two- or three-tiered contractual arrangements, physicians' payment methods, clienteles served, and means of pooling risks. Classifications of these kinds may represent or aid in generating a valid typology to help managers, consumers, providers, and analysts understand better how HMOs operate and which factors are critical in the dynamic managed-care industry.

Contraceptive Attitudes and Intention to Use Condoms in Sexually Experienced and Inexperienced Adolescent Males

Abstract: In the 1988 National Survey of Adolescent Males, about three fifths of sexually experienced and inexperienced adolescent males intending to have sex in the next year reported there is an “almost certain chance” they will use a condom with a hypothetical future partner. Sexually experienced males report lower perceived costs for condom use related to embarrassment (assessed in a subjective expected utility format) than do inexperienced males. However, experienced males perceive condoms as being more costly in terms of reduction of pleasure. The perceived benefits of using condoms in terms of preventing pregnancy and gaining appreciation from the partner, and attitudinal endorsement of male responsibility in contraception more generally, are similar for the two groups. Among both the sexually experienced and inexperienced, believing that males are responsible for contraception and, to a lesser extent, perceiving that condoms have low costs in terms of reduction of pleasure and high benefits in gaining the p...

Spells without health insurance: distributions of durations and their link to point-in-time estimates of the uninsured.

Abstract: To be able to design effective policies that will provide financial access to medical care to the uninsured, we need to know how many people experience long versus short spells without health insurance. Previous studies of the characteristics of the uninsured have relied almost exclusively on data from a point in time. Using the Survey of Income and Program Participation (SIPP), this paper provides a link between the distributions of four characteristics of the uninsured at a point in time and the expected uninsured spell lengths of people in specific subgroups of each characteristic. Our findings indicate that half of all uninsured spells end within 4 months while only 15% last longer than 24 months. Also, people who are employed (either full-time or part-time) in the first month of an uninsured spell are highly likely to have short uninsured spells, while people who are unemployed or out of the labor force are more likely to have long uninsured spells. This implies that efforts to increase health insurance coverage via employer mandates should proceed cautiously until we know how many people with long uninsured spells are employed.

The U.S. 1986 Immigration Reform and Control Act and undocumented migration to the United States

Abstract: One of the major goals of the 1986 Immigration Reform and Control Act (IRCA) is to reduce the number of undocumented immigrants coming to and residing in the United States. This goal is pursued by allocating increased resources to Border Patrol enforcement, imposing penalties on employers for hiring undocumented workers, and offering to legalize the undocumented population that has resided in the country for a substantial period of time. This paper evaluates the impact of IRCA on the flow of undocumented migrants across the U.S.-Mexican border by analyzing a monthly time series of Border Patrol apprehensions from January 1977 to September 1988 within the context of a multivariate statistical model. The model provides a good fit to the data (R2 = 0.94), and our results indicate that INS resources, Mexican population growth, comparative economic conditions on both sides of the border, and seasonal factors related to the agricultural planting and harvesting cycle are all determinants of border apprehensions and, by implication, of the flow of undocumented migrants to the United States. IRCA's impacts on the number of ‘apprehensions averted’ operate mainly through changes in INS effort, the SAWs agricultural legalization program, and other IRCA-related factors. Our analysis concludes that the effects of IRCA, though perhaps smaller than sometimes alleged, were associated with a cumulative net reduction in linewatch apprehensions of nearly 700,000 in the 23-month period following enactment of the law. The associated reduction over the same period in the number of illegal border crossings may be as high as 2 million.

Household patterns of older women. Some international comparisons.

Abstract: Comparative analyses based on aggregate data have shown that the percentage of older women living alone has risen dramatically during recent decades, a pattern repeated in many European and North American countries. This article investigates the correlates of the decision to live alone, using individual-level data from five countries and a parallel analytic approach. The major categories of factors analyzed here are kin availability, financial resources, and disability and health status. Several common patterns of findings emerge for the group of countries considered: Larger kin networks and the presence of severe disabilities reduce the probability of living alone, whereas higher income increases the probability of living alone. Despite these similarities in individual-level correlates, there remain some differences across countries in the levels of single-person households, and these might be attributable to macrolevel forces such as housing and social welfare policies.

Understanding the recent growth in Medicare physician expenditures.

Abstract: This study employs several large Health Care Financing Administration data sets for 1983 and 1985 to examine the recent growth in Medicare physician services. The study concludes that the recent growth (approximately 15% in real terms between 1983 and 1985) has been more rapid in areas with higher incomes per capita and suggests that this may be related to faster adoption and diffusion of new medical technologies in these areas. The volume of physician services had grown considerably faster for those specialists who utilize newer procedures and technologies than for those who do not. The study also provides evidence that the sharp increase in assignment rates in recent years because of the introduction of the physician participation program also contributed to the growth in physician services during this period. Medicare's prospective payment system, which controlled hospital payments and encouraged hospitals to become more efficient, had at most a small positive impact on the growth in Part B spending. Finally, the freeze on physicians' fees did not seem to have had a major impact on the volume of physician services. ( JAMA . 1990;263:1658-1661)

Medicaid spenddown in nursing homes.

Abstract: This paper employs information from nationally representative surveys to examine the incidence and causes of Medicaid spenddown among disabled elderly persons About 10% of nursing home discharges experience "asset spenddown," the process of converting from private pay to Medicaid In contrast, over 50% of nursing home patients remain private pay throughout their stays In addition, becoming a Medicaid patient is more common among community residents than among nursing home residents Implications of findings for health care policies are discussed

The nursing home market and hospital discharge delays.

Abstract: One way for hospitals to respond to the incentives in Medicare's PPS is to reduce the patients' length of stay by discharging to nursing home care those patients who no longer require hospital care but are not well enough to go home to informal care. In this study, we find that patients experience more discharge delays at hospitals located in areas with few nursing home beds and in states with prospective Medicaid nursing home reimbursement policies. Hospitals with their own nursing home units or swing beds experience earlier discharges, other things being equal. Our findings suggest that some hospitals are at a disadvantage compared with others and that a policy response may be warranted.

The Net Economic Value of Recreation on the National Forests: Twelve Types of Primary Activity Trips Across Nine Forest Service Regions

Abstract: The PARVS survey was used to estimate demand models on Forest Service land; for 12 activities in 9 Forest Service retions. A reverse multinomial logit gravity model was used. A first stage estimates probablity that a trip observed at a recreation site originated from a county. A second state uses traditional travel cost models to derive site demand, and used to estimate consumer surplus. Relative values for different primary activity trips across different regions, and within regions, are examined.

Costs of community care for disabled elderly persons: the policy implications.

Abstract: This paper presents results from our analysis of the National Long-Term Care Channeling Demonstration Project data. We used this data to estimate the costs of community-based long-term care services for disabled elderly persons. Our results indicate that both costs per community day and the likelihood that any costs would be incurred, would increase noticeably if a program similar to the Channeling project were implemented nationally. To illustrate the effects of disability-based eligibility criteria on total program costs, we present unit costs in conjunction with numbers of persons having different levels of ADL dependency.

Morbidity, disability, and long-term care of the elderly: implications for insurance financing.

Abstract: A scarcity of empirical information to specify appropriate provisions and base rates for coverage has hindered the development of long-term-care (LTC) insurance. Data from three nationally representative surveys on the prevalence of morbidity and functional limitations among the elderly population suggest that health status among older Americans is highly dynamic, especially at higher disability levels. The bioactuarial data may help insurers define potential markets of purchasers of policies, and identify the numbers of persons with disabilities severe enough to trigger use of benefits. If the accuracy of individual service predictions could be increased further, reserve requirements and overall costs to LTC insurance carriers might be reduced.

Area variations in selected Medicare procedures

Abstract: Widespread variation in the use of physician services has led to the call for research on the effectiveness of different medical procedures. The underlying implication is that if the effectiveness of procedures were better understood, then utilization and expenditures could be reduced in some areas. Thus, fiscal problems facing the Medicare program in the coming years could be addressed without the need for new regulatory measures, such as expenditure targets. In this DataWatch, we present new evidence on area variations in twenty selected Medicare procedures. In general, the area variation studies seem to have two kinds of problems. The first is that there has been only a very limited amount of control for other explanatory variables. To the extent other factors could explain these variations, less needs to be explained by “practice styles.” Second, the use of small areas is problematic because many of the procedures that are analyzed occur relatively infrequently. One needs relatively large populations to obtain stable statistics; otherwise, large variations should be expected for fairly simple statistical reasons. This study differs from previous efforts in that it uses data from a large number of relatively large geographic areas. The data are based on use of services by Medicare beneficiaries for twenty procedures in 1985. In addition to presenting data on variations across areas, we use multivariate regression techniques to control for a large number of variables that could explain area variations. We also use a weighted least squares regression procedure, which controls for the effects of differences in area size on the efficiency of the parameter estimates. Finally, we use two-stage least squares procedures to control for the simultaneous relationship between utilization and variables, such as assignment rates and the area’s supply of physicians in particular specialties.

Consumer Issues and the Elderly.

Abstract: In preparing for this talk on consumer issues facing the elderly, I was intimidated by the enormity of the possible issues. But as an economist, I was also struck by how closely the issues track what economists like to term market failures and redistributional issues. Rather than the mainstream concerns of microeconomics of maxi mization and efficiency issues, consumer interests focus on the prob lems and issues that the market fails to appropriately address. Effi ciency and pure competition constitute the main thrust of neoclassical economic analysis; what is being discussed here are the problems that such a laissez faire system cannot resolve. Consequent ly, there is a natural link between researchers interested in redistribu tional issues (who gets what) and the market failures that require regulation or direct government provision. This emphasis leads rather quickly to research with practical appli cations and away from the realm of the purely theoretical—an em phasis with which I am sympathetic. In fact, when I refer to myself as a "defrocked" economist, I am placing myself squarely in the camp of skepticism about tb i ability of the market to always find the "just" solution. I am glad to see so much interest in how economic issues affect individuals and what adjustments or constraints to the free market would improve the lot of individuals. The 1980s will be remembered, I believe, as the decade of the cult of the free market. Deregulation was a major goal of many promi nent politicians in the 1980s—as was reducing the general role of the

Deciphering Medicaid data: issues and needs.

Abstract: The wide range of data bases that can be used for Medicaid analyses and research are reviewed in this article. The Health Care Financing Administration, State Medicaid agencies, and other groups have developed useful data bases and made them available to the public. Efforts could be made to obtain better quality national data, including annual reports on State participation, expenditures and program characteristics, and person-based data bases about Medicaid clients and services. State-level analyses and research could be enhanced and disseminated more widely. More complex data collection and analysis efforts are an inevitable tradeoff for the flexibility of the Federal-State structure of Medicaid.

Service Credit Banking

Abstract: Informal care provided by family and friends is widely recognized as one of the key factors in keeping long-term care financially manageable for individuals as well as for public programs Sociodemographic trends predict that the demand for formal and informal home care services among the elderly will increase faster than the supply Programs that allow volunteers to earn credits later redeemable for comparable services when they may be required are beginning to be examined as a way to help fill the need for respite services and other basic home care services This paper examines key considerations of the service credit concept in the context of existing programs and initiatives designed to encourage its development

Kin availability and the living arrangements of older unmarried women: Canada, 1985

Abstract: A model of the living arrangements of older unmarried women is presented using data from a 1985 survey of the Canadian population. Living arrangements are represented by a multichotomous variable distinguishing those living alone with children with siblings and with others. The hypothesized determinants of living arrangements include income disability status the array of available kin and education. Results from a multinomial logit estimation of the model confirm the importance of income disability and kin availability; particularly interesting is the significant effect of the number of grandchildren on the relative propensities to live alone with children and with siblings. (SUMMARY IN FRE) (EXCERPT)

Giving physicians incentives to contain costs under Medicaid.

Abstract: In this article, the risk arrangements in Medicaid programs that put physicians at risk are summarized These programs--partial capitation and health insuring organizations--pay physicians a capitation amount to cover some or all physician services Physicians also receive part of the savings from reduced hospitalization Most of these programs have successfully lowered Medicaid costs They could serve as models for other Medicaid programs, State-level programs to cover people ineligible for Medicaid, and programs abroad, such as in the United Kingdom

The Findings and Policy Implications of the GAO Report and the Urban Institute Hiring Audit.

Abstract: In March, 1990 die General Accounting Office of the United States submitted its third and final mandated report on the impact and implementation of the 1986 Immigration Reform and Control Act (IRCA). Its conclusion was diat the law had given rise to "widespread discrimination" against "foreignsounding" and "foreign-looking" job applicants. This result had been antic? ipated during the two-decade debate over IRCA by opponents of the law's principal policy innovation: employer sanctions. Sanctions were intended to right an asymmetry in American law that made it illegal for undocumented aliens to enter and work in the United States but imposed no penalties on employers who hired them. Righting this asymmetry involved the largest expansion of labor-related regulation since 1970, as well as the broadest regulatory expansion to take place during the fiercely antiregulatory Reagan Administration. By deputizing employers as "junior immigration officers" (Roberts and Loehr, 1987), sanctions for the first time brought the hitherto obscure and little-encountered world of immigration law and immigration law enforcement to the nation's workplace and indeed, because sanctions govern all hiring transactions, in theory, to the homes of die nation's citizens. The battle for sanctions was a long and arduous one that forced its proponents to consent to a series of major political trades. Among other things, it led to the enactment of the two largest legalization programs in recent history (one for aliens who had been in the U.S. since 1982, the other

Changes in Medicare skilled nursing facility benefit admissions.

Abstract: In this article, the changes in Medicare skilled nursing facility (SNF) benefit admissions from 1983 through 1985 are examined and factors that influence changes in access since the implementation of Medicare's prospective payment system are analyzed. During this period, use of the SNF benefit increased nationally by 21 percent. Multivariate analysis is used to determine factors associated with changes in admissions. Changes in SNF benefit admissions were found to be negatively associated with changes in area hospitals' lengths of stay and changes in hospitals' discharges. Medicaid reimbursement policies were also shown to affect changes in utilization.

Hospital back-up days: impact on joint Medicare and Medicaid beneficiaries.

Abstract: In this article the question of whether nursing home market characteristics affect the ability of hospitals to discharge patients to nursing homes is examined. Also examined is the question of whether joint Medicare and Medicaid beneficiaries have a more difficult time being placed than do other patients. The principal conclusions are first, that the nursing home bed supply and the type of Medicaid payment system affect the ability of hospitals to discharge patients to nursing homes. Joint Medicare and Medicaid beneficiaries have a more difficult time being placed in nursing homes in States with fewer beds and more restrictive Medicaid payment policies, and joint beneficiaries do not appear to have longer stays in hospitals. Rather, they have a greater likelihood of being discharged to home.