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Showing papers by "Urban Institute published in 1995"


Journal ArticleDOI
TL;DR: In this article, a conceptual framework for metropolitan opportunity and a model of individual decision making about issues affecting youth's future socio-economic status is presented, where decisions are based on the decisionmaker's values, aspirations, preferences, and subjective perceptions of possible outcomes, which are all shaped by the local social network.
Abstract: We present a conceptual framework for metropolitan opportunity and a model of individual decision making about issues affecting youth's future socioeco‐nomic status. Decision making and its geographic context have objective and subjective aspects. Objective spatial variations occur in the metropolitan opportunity structure—social systems, markets, and institutions that aid upward mobility. Decisions are based on the decision‐maker's values, aspirations, preferences, and subjective perceptions of possible outcomes, which are all shaped by the local social network (e.g., kin, neighbors, and friends). We also review the psychological literature on decision making. We hypothesize that the decision‐making method varies with the range of opportunities considered: Those with fewer options adopt a less considered method wherein mistakes and short‐term focus are more likely. Our review also finds empirical evidence that the local social network has an important effect on youth's decisions regarding educat...

474 citations


Journal ArticleDOI
TL;DR: The results indicate that both light and heavy drinkers are much less price elastic than moderate drinkers, and cannot reject the hypothesis that the very heaviest drinkers have perfectly price inelastic demands.

391 citations


Posted Content
TL;DR: An examination of recent trends in self-reported health indicates that the health declines observed during the 1970s generally reversed during the 1980s, which belies the argument that lower adult mortality implies worse health.
Abstract: Data from the National Health Interview Survey and elsewhere showed a trend toward worsening self-reported health among American men and women in middle age and older during the 1970s. This evidence - combined with the significant declines in age-specific mortality observed since the 1960s - led some researchers to suggest that, on average, the health of the older population is declining. We examine recent trends in self-reported health and find that the health declines observed during the 1970s generally reversed during the 1980s. This shift would appear to belie the notion that lower adult mortality necessarily implies worse health. We argue further that the reversals observed during the 1980s also call into question whether trends in self-reported health during the 1970s reflected actual health declines. We suggest that changes in the social and economic forces influencing the options available for responding to health problems, combined with earlier diagnosis of pre-existing conditions, provide a more plausible explanation for these trends - an explanation that is consistent with data from both the 1970s and 1980s.

130 citations


Journal Article
TL;DR: Evidence is presented that, even for economically developed countries, the income distribution of a nation is an important determinant of its mortality, and the results of this study suggest that the relatively unequalincome distribution of the United States is anImportant contributing factor to its low life expectancy relative to other high-income countries.
Abstract: The absence of a correlation between age-adjusted death rates and the average income levels of economically developed countries has led researchers to conclude that income does not affect the mortality levels of economically developed countries. The mortality experiences of the former Soviet Union and some of the eastern European countries have further brought into question the importance of income's distribution in determining mortality among economically developed countries; prior to its breakup, the income distribution of the Soviet Union was as equal as that of Sweden, yet the life expectancy of the Soviets has been dramatically shorter than that of the Swedes. Using insights from a longitudinal microanalysis of U.S. mortality, this study presents evidence that, even for economically developed countries, the income distribution of a nation is an important determinant of its mortality. The results of this study also suggest that the relatively unequal income distribution of the United States is an important contributing factor to its low life expectancy relative to other high-income countries.

81 citations


Journal ArticleDOI
TL;DR: In this article, the authors used tabular and mapping presentations of 1990 census tract data to investigate variations in adverse socioeconomic conditions across Washington, DC, neighborhoods and examined the levels of exposure of youth of different races or ethnicities to these adverse conditions.
Abstract: This article uses tabular and mapping presentations of 1990 census tract data to investigate variations in adverse socioeconomic conditions across Washington, DC, neighborhoods. It also examines the levels of exposure of youth of different races or ethnicities to these adverse conditions. Underlying this analysis is the premise that aggregate neighborhood conditions related to poverty and welfare status, educational attainment, out‐of‐wedlock births, employment, drug use, and crime serve as proxies for resident youth's perceptions of the opportunity structure as filtered through the local social network. Empirical analyses show two distinct clusters of indicators that vary consistently across Washington neighborhoods; one is related to socioeconomic status, drug use, and fertility, and the other is related to crime rates. Both sets vary systematically by the racial‐ethnic composition of youth in the neighborhood. Youth in black, female‐headed families are exposed to the most negative neighborhood...

51 citations


Journal ArticleDOI
TL;DR: This analysis reveals that the relative stability of the uninsurance rate for the entire nonelderly population belies more significant changes in insurance coverage--and lack of coverage--among various groups.
Abstract: Data from the Current Population Survey are used in this DataWatch to explore the changing composition of health insurance coverage of the U.S. nonelderly population. The authors analyze ...

46 citations


Journal Article
TL;DR: It is found that only a small share of these funds were available to cover the costs of uncompensated care, and one method to ensure that funds are used for health care would be to reprogram funds into health insurance subsidies.
Abstract: Medicaid disproportionate share hospital (DSH) and related programs, such as provider-specific taxes or intergovernmental transfers (IGTs), help support uncompensated care and effectively reduce State Medicaid expenditures by increasing Federal matching funds. We analyze the uses of these funds, based on a survey completed by 39 States and case studies of 6 States. We find that only a small share of these funds were available to cover the costs of uncompensated care. One method to ensure that funds are used for health care would be to reprogram funds into health insurance subsidies. An alternative to improve equity of funding across the Nation would be to create a substitute Federal grant program to directly support uncompensated care.

38 citations


Journal Article
Gregory Acs1
TL;DR: It appears that the rising cost of health insurance coupled with falling incomes and profits during the recession account for the fall in health insurance coverage between 1988 and 1991.
Abstract: This paper uses regression-based decompositions to examine the downward trend in insurance coverage between 1988 and 1991. I find that falling family incomes account for much of the decline in overall insurance coverage, while a secular decline in insurance coverage across all industries, firm sizes, employment statuses, income levels, and demographic groups accounts for most of the decline in employer-sponsored insurance among workers. Rising unemployment and changing patterns of industrial employment explain little of the decline in coverage across the entire population. Taken together, these results suggest that fewer employers are offering health coverage, workers are finding it difficult to pay their share of the premiums, and those without access to employer-sponsored plans are finding it harder to purchase nongroup insurance. Thus, it appears that the rising cost of health insurance coupled with falling incomes and profits during the recession account for the fall in health insurance coverage between 1988 and 1991.

31 citations


Journal ArticleDOI
TL;DR: Although prenatal services increased in some areas, significant problems persisted in others and 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.
Abstract: 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.

29 citations


ReportDOI
TL;DR: This article found that race and education differences in health status of middle-aged men can explain a substantial fraction of black/white differences in labor force attachment and essentially all of the gap between men with different levels of education.
Abstract: The labor force participation rates of older, working-aged black men and men with lower levels of education have historically been significantly lower than those of white men and men with more education, respectively. This paper uses data from the alpha release of the Health and Retirement Survey (HRS) to examine the extent to which variation in health and job characteristics can account for these differences. Our analysis suggests that race and education differences in health status of middle-aged men can explain a substantial fraction of black/white differences in labor force attachment and essentially all of the gap between men with different levels of education. (Journal of Human Resources 1995; 30(5): S227-S267).

27 citations


Journal ArticleDOI
TL;DR: Using a survey of family planning clinics in the continental United States that received Title X funding conducted by The Urban Institute in 1993, those clinics were identified that had made substantial efforts to serve male clients.
Abstract: Using a survey of family planning clinics in the continental United States that received Title X funding conducted by The Urban Institute in 1993 those clinics were identified that had made substantial efforts to serve male clients The final sample size was 567 clinics 10% of their clients were men and 31% reported that their male clientele had increased in the previous 5 years During January through March 1995 follow-up telephone interviews were conducted with 25 selected clinics that reported a 10% male share of clients The clinics were classified into 5 types: 1) 7 clinics with a family planning focus beginning to provide primary care to attract more men; 2) 7 clinics with a family planning focus using community outreach and the partners of female clients to recruit men for clinic services; 3) 6 primary health care clinics beginning to place more emphasis on male reproductive health; 4) 3 hospital-based clinics providing comprehensive and reproductive health care for young men; and 5) 2 school-based clinics providing sports physicals primary health care and reproductive health services In Type 1 clinics males made up 10-40% of clients They also screened for testicular cancer and provided infertility mental health and nutrition counseling services Type 2 clinics had an average of 10% male clients and offered male infertility services nutrition counseling and specific STD and HIV services for males in the Hispanic and immigrant communities Type 3 clinics promoted the male role in family planning decision making and STD prevention A substantial proportion of the clientele was low-income males but men who came for vasectomies tended to have higher incomes Type 4 clinics catered to 20-40% male clients with outreach programs for gay minority men and sessions on stopping domestic violence male role in family planning and responsible parenthood Type 5 clinics had 40-45% males and provided mental health counseling HIV risk assessment and screening for testicular cancer

Journal ArticleDOI
TL;DR: In this paper, the authors examined the tradeoffs between administrative streamlining and accomplishing substantive program objectives in the context of the Food Stamp Program, an important component of the United States' safety net for providing low-income assistance.
Abstract: The recent report produced by Vice President Gore's committee on government efficiency highlights the importance of streamlining government operations. But often there are trade-offs between administrative streamlining and accomplishing substantive program objectives. This article examines these tradeoffs in the context of the Food Stamp Program, an important component of the United States' safety net for providing low-income assistance. We estimate impacts on both administrative costs and substantive outcomes (participant food expenditures) resulting from issuing program benefits in the form of checks rather than the usual food coupons. The findings, which are based on experimental tests of the cashout approach in parts of Alabama and California, suggest that significant cost savings can be attained through cashout but that these savings may be achieved at the cost of weakening the program's ability to achieve its substantive objective of encouraging food use.

Journal Article
TL;DR: This work uses data from the 1987 National Medical Expenditure Survey to examine how net health insurance benefits are distributed in the employment-related insurance market and finds the tax subsidy from employer health insurance contributions to be a crucial determinant of the net benefit distribution.
Abstract: The recent health care reform debate has questioned whether the health insurance market effectively pools risks and transfers income across states of health. We use data from the 1987 National Medical Expenditure Survey to examine how net health insurance benefits are distributed in the employment-related insurance market. We find this market to transfer income from those in good health to those with health problems and the tax subsidy from employer health insurance contributions to be a crucial determinant of the net benefit distribution. To the extent society views these transfers as meritorious, our findings suggest caution regarding initiatives to limit or eliminate the tax subsidy.

Journal Article
TL;DR: Using State-level data from 1984-92, the results indicate that Medicaid enrollment, Federal Medicaid policy, and State policy are significantly related to Medicaid expenditure growth.
Abstract: Expenditures for the Medicaid program grew at the alarming and unexpected average annual rate of nearly 20 percent from 1989 ($58 billion) to 1992 ($113 billion). These statistics raise a critical question: What caused spending to grow so dramatically? Using State-level data from 1984-92, this analysis examines the determinants of Medicaid expenditure growth. The results indicate that Medicaid enrollment, Federal Medicaid policy, and State policy are significantly related to Medicaid expenditure growth. The analysis also finds the prevalence of acquired immunodeficiency syndrome (AIDS) to be significantly related to Medicaid expenditures.

Journal ArticleDOI
Martha R. Burt1
TL;DR: Several factors affect Wright and Devine's efforts to estimate the size of the homeless population, including the purpose of the estimate, implicit or explicit definitions of homelessness used in the estimates, and the time period covered by the data sets used.
Abstract: Several factors affect Wright and Devine's efforts to estimate the size of the homeless population The most critical ones are the purpose of the estimate, implicit or explicit definitions of homelessness used in the estimate, and the time period covered by the data sets used in the calculations

Journal ArticleDOI
TL;DR: Expansion of managed care choices should certainly be part of any restructuring, but careful attention to improving the basic fee-for-service Medicare program--which will continue to serve a majority of beneficiaries for many years to come--also is needed.
Abstract: Any restructuring or reform of Medicare should first and foremost preserve the integrity of the program. Contrary to current rhetoric, Medicare offers mainstream medical care for the most difficult-to-insure Americans, and over the past ten years its record of holding down costs has been better than that of the private insurance sector. For the very long term, when demographic changes place even greater pressures on Medicare, all dimensions of the program need to be considered in the search for a long-range solution, including asking beneficiaries and/or taxpayers to contribute more to the program. Expansion of managed care choices should certainly be part of any restructuring, but careful attention to improving the basic fee-for-service Medicare program—which will continue to serve a majority of beneficiaries for many years to come—also is needed.


Journal ArticleDOI
TL;DR: This article examined the influence of research on policy and vice versa using three widely believed propositions: government spending is wasteful or ineffective and can readily be cut back in order to reduce the deficit; welfare should be time limited and made conditional on people's behavior; education and training are (more than ever) the ticket to individual and national prosperity.
Abstract: This lecture, given to the Society of Government Economists in January 1995, examines the influence of research on policy and vice versa using three widely believed propositions. The first is that government spending is wasteful or ineffective and can readily be cut back in order to reduce the deficit; the second is that welfare should be time limited and made conditional on people's behavior; the third is that education and training are (more than ever) the ticket to individual and national prosperity. The paper explores the interplay of facts of economic analysis with political and institutional constraints and public values.

Journal ArticleDOI
W P Welch1, M Wade1
TL;DR: Data from nine HMOs indicate that, on average, Aid to Families with Dependent Children (AFDC) and poverty-related Medicaid enrollees cost 13 percent more than commercial enrollee cost, and if one adjusts for enrollees' age and sex, Medicaid costs are 23 percent higher than commercial costs.
Abstract: Under several national health care reform proposals in 1994, many Medicaid beneficiaries would have enrolled in health maintenance organizations (HMOs) with other persons. Several states already enroll Medicaid beneficiaries in HMOs with commercial enrollees. This DataWatch examines the cost of Medicaid enrollees in HMOs relative to the cost of commercial enrollees. Data from nine HMOs indicate that, on average, Aid to Families with Dependent Children (AFDC) and poverty-related Medicaid enrollees cost 13 percent more than commercial enrollees cost. If one adjusts for enrollees' age and sex, Medicaid costs are 23 percent higher than commercial costs.

Journal Article
TL;DR: 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.
Abstract: 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.

Journal ArticleDOI
TL;DR: There is substantial variation across the states in utilization levels (Florida 38 percent above the U.S. mean; Vermont and Montana 29 percent below the mean) and a much greater range at the metropolitan area level.
Abstract: This article investigates the geographic variation in Medicare physician services by type of service. Using 1990 Medicare beneficiary samples, age-sex-race adjusted population based physician service rates are computed. Physician services are measured using relative value units (RVUs)from the Medicare feeschedule. There is substantial variation across the states in utilization levels (Florida 38 percent above the U.S. mean; Vermont and Montana 29 percent below the mean) and a much greater range at the metropolitan area level. With the exception of major surgery, urban area benefciaries generally receive higher amounts of most evaluation and management services (particularly consultations), imaging services, and diagnostic testing. If volume performance standards (or an entitlement cap) were established at a state or area level, policymakers would have to address issues of geographic variation.


Journal Article
Dubay Lc1, Norton Sa1, Moon M1
TL;DR: This analysis shows that for hospitals with a significant commitment to maternity and infant care, the burdens of uncompensated care were 28.5% lower than they would have been without the expansions of Medicaid.
Abstract: Hospitals' bad debt and charity care increased by nearly 30% between 1987 and 1990. However, beginning in 1987, federal legislation expanded Medicaid eligibility to pregnant women and infants with family incomes up to 133% of the federal poverty level, and gave states the option to extend coverage up to 185% of poverty. These expansions likely reduced the need for free hospital care. Controlling for other factors associated with provision of uncompensated care, this analysis shows the Medicaid expansions reduced uncompensated care by roughly 5.4%. For hospitals with a significant commitment to maternity and infant care, the burdens of uncompensated care were 28.5% lower than they would have been without the expansions.

Journal Article
TL;DR: The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS, and the organization of service supply in a region may affect service provision in the HopD suggesting the need for a transition to prospective payment.
Abstract: OBJECTIVE. To determine if implementation of a PPS for Medicare hospital outpatient department (HOPD) services will have distributional consequences across hospital types and regions, this analysis assesses variation in service mix and the provision of high-technology services in the HOPD. DATA. HCFA's 1990 claims file for a 5 percent random sample of Medicare beneficiaries using the HOPD was merged, by hospital provider number, with various HCFA hospital characteristic files. STUDY DESIGN. Hospital characteristics examined are urban/rural location, teaching status, disproportionate-share status, and bed size. Two analyses of HOPD services are presented: mix of services provided and the provision of high-technology services. The mix of services is measured by the percentage of services in each of 14 type-of-service categories (e.g., medical visits, advanced imaging services, diagnostic testing services). Technology provision is measured by the percentage of hospitals providing selected high-technology services. FINDINGS/CONCLUSIONS. The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS. HOPDs in major teaching hospitals and hospitals serving a disproportionate share of the poor play an important role in providing routine visits. HOPDs in both major and minor teaching hospitals are important providers of high-technology services. Other findings have implications for the structure of an HOPD PPS as well. First, over half of the services provided in the HOPD are laboratory tests and HOPDs may have limited control over these services since they are often for patients referred from local physician offices. Second, service mix and technology provision vary markedly among regions, suggesting the need for a transition to prospective payment. Third, the organization of service supply in a region may affect service provision in the HOPD suggesting that an HOPD PPS needs to be coordinated with payment policies in competing sites of care (e.g., ambulatory surgical centers).

Journal Article
TL;DR: Multivariate analyses indicate the importance of type of insurance and source of primary health care in affecting a woman's selection of her reproductive health care provider.
Abstract: Providers of reproductive health services, including clinics and office-based physicians, face new challenges as the American health system progresses toward managed care. Although services for low-income women are often subsidized, the average out-of-pocket payments for reproductive health services are the same for women with incomes below and above 200% of the poverty level. Although many women, especially those classified as low income, use clinics, most say that they would prefer to receive care in a private physician's office and in a place where they can get general health care as well. Multivariate analyses indicate the importance of type of insurance and source of primary health care in affecting a woman's selection of her reproductive health care provider. Specialized providers such as family planning clinics need to consider how they can blend with managed care plans.

Journal ArticleDOI
TL;DR: This paper outlines a simple proposal to maintain utilization data in the face of managed care growth, where health maintenance organizations (HMOs) would be required to submit claims and in return would be paid a percentage of what Medicare would pay fee-for-service providers.
Abstract: This paper outlines a simple proposal to maintain utilization data in the face of managed care growth. Health maintenance organizations (HMOs) would be required to submit claims (encounter-level data) and in return would be paid a percentage of what Medicare would pay fee-for-service providers. The capitation payment rate would be lowered to maintain budget-neutrality. This proposal would enable the collection of key data that might not otherwise be captured in a Medicare program dominated by HMOs and other forms of managed care. The data are necessary to drive Medicare policies and to gauge the impact of changes to the program. The program would be well advised to make the small additional investment to make the data system complete. The key issue in implementing such a proposal will be HMOs' ability to generate those data at reasonable cost.

Journal ArticleDOI
TL;DR: In this article, the authors analyzed the economic impacts of immigrants on the U.S. economy over the last decade using 1980 and 1990 Census data and focused on the effects of immigrants who entered the United States between 1980-1990, finding that the average worker in areas of high and medium recent immigration had a more negative effect on the wages of native labor in 1990 as compared with 1980.
Abstract: I. INTRODUCTION According to the 1990 Census, 8.6 million immigrants arrived in the United States between 1980 and 1990 - three million more than those who entered a decade earlier. The high immigration of the last decade has brought much attention to the economic impacts of immigrants on the U.S. economy. Critics of U.S. immigration policy argue that the economy of the United States cannot absorb immigrants as in the past (Briggs, 1984; Huddle, 1993). To support this claim, they point to the stagnant wages, slow job growth, and declining incomes of less-skilled workers (Lamm and Imhoff, 1985; Huddle, 1993). Advocates of this position argue not only that immigrants are not what they used to be, but that the economy is not what it used to be. Consequently, immigration restrictions are being advocated under the assertions that natives are being hurt by the recently arrived immigrants and that the U.S. labor market cannot absorb such high immigration levels. Studies using 1970 and 1980 Census data show that the effects of immigration on native labor are trivial (Grossman, 1982; Borjas, 1987; Altonji and Card, 1991; Butcher and Card, 1991). However, research focusing on high immigration areas finds mixed results (Card, 1989; Muller and Espenshade, 1985; Smith and Newman, 1977). Available research is of little help in addressing the question of whether the current economy can continue to absorb immigrants as in the past. Most studies are based on a one-point-in-time data, such as 1970 or 1980 Census data, which cannot support analysis of changes over time. In addition, most studies analyze the effects of all immigrants rather than recent immigrants, further impeding assessment of the economic effects of new immigration. By answering three inter-related questions, this paper addresses the issue of changes in the capacity of U.S. and local labor markets to absorb immigrants. (i) Was immigration more harmful in 1990 than in 1980? (ii) Is there a saturation point after which higher immigration is detrimental to native labor, and if so, was there any change in this pattern between 1980 and 1990? (iii) Has the labor market standing of the typical native worker in main immigration gateways deteriorated during the last decade? The analysis here answers these questions using 1980 and 1990 Census data and focuses on the effects of immigrants who entered the United States between 1980 and 1990. If a reduction in economy's capacity to absorb immigrants has occurred, the increase in recent immigrants as a percent of the labor market should have had a more negative effect on the wages of native labor in 1990 as compared with 1980. If there is a saturation point after which additional immigration can hurt native labor, then immigration effects on wages should vary according to the size of the immigration flow. The analysis here also tracks the 1980-to-1990 performance of the average worker in each area with different levels of immigration. If the capacity of local areas to absorb immigrants has declined, the wages of the average worker in areas of high and medium recent immigration should have deteriorated relative to those in areas of low recent immigration. II. A BRIEF REVIEW OF U.S. IMMIGRATION POLICY Immigration legislation in the United States was virtually nonexistent until 1872, when the Chinese Exclusion Act was passed. That Act suspended Chinese immigration and barred naturalization for existing Chinese immigrants. The late 1800s gave witness to a huge rise in new arrivals, mostly from Western and Northern Europe. The same economic, religious and political conditions that prompted this migration, coupled with technological advances in transportation at the turn of the century, brought increasing numbers of immigrants from Southern and Eastern Europe as well. Immigration laws were enacted not only to stem the rapid inflow of newcomers but to limit the quantity and influence the quality of individuals emigrating from certain areas (Vialet, 1990). …

Journal ArticleDOI
TL;DR: The last drop of heroin injected into a scarred vein running along his outer forearm was the last drop he injected into the needle, and his eyes rolled back and asphyxiated gasps rattled from inside his throat.
Abstract: Scotty injected his last drops of heroin into a scarred vein running along his outer forearm. On this chilly, late winter afternoon, I had been watching him, his street partner Jim, and another homeless heroin addict, Leo, share a $20 bag of black tar heroin in their homeless encampment/shooting gallery. For the past year, as part of an HIV-AIDS prevention study, I have been spending much of my time with a network of heroin addicts who live under a stretch of San Francisco's downtown freeways. As I was walking toward the back of the camp where another four men were fixing heroin, out of the corner of my eye I saw Scotty fall to the ground. As he jerked in the dirt, his eyes rolled back and asphyxiated gasps rattled from inside his throat. "Oh my God," I thought as I ran to his convulsing body, "he's gonna die!" What was I supposed to do? Call 911 from the bushes under the freeway? Would Scotty stay alive while I dragged him over the ten-foot-high chain-link fence surrounding our camp to an anonymous stretch of sidewalk? Would I even be able to find a functioning pay phone? I must have said something about calling 911, because I vaguely heard Jim reassuring me, "No, don't. He's okay." Scotty was clearly not okay, but, from the perspective of the addicts in the shooting gallery, the paramedic authorities and the police who would follow them were even less okay. At a total loss, I massaged Scotty's chest, hoping to somehow relax his breathing. Fortunately, at this point Jim took more coherent control. He had me grab Scotty's arms and pull them above his head, jamming him into an upright position. Following the gestures from a long-forgotten junior high school CPR training session, but having no faith in their efficacy, I placed my knee in the center of Scotty's back to arch his torso and maybe open his clogged respiratory system. Jim was massaging Scotty's shoulders, while Leo, who had woken up

Journal Article
TL;DR: It is concluded that effective cost containment may require implementation of direct volume controls in addition to a PPS, as well as changes in beneficiaries, prices, case mix, encounters per beneficiary, services per encounter, and intensity per service.
Abstract: Medicare hospital outpatient expenditures are growing rapidly. In response, Congress mandated implementation of a prospective payment system (PPS). The potential cost control effectiveness of a PPS is assessed in this paper by decomposing growth in charges into changes in beneficiaries, prices, case mix, encounters per beneficiary, services per encounter, and intensity per service. This paper examines aggregate growth rates and rates disaggregated by type of service, highlighting rapid growth in surgery and imaging services. Findings indicate that 69% of observed growth is attributable to factors that would be unaffected by an encounter-based PPS (i.e., beneficiaries, prices, case mix, and encounters per beneficiary). We conclude that effective cost containment may require implementation of direct volume controls in addition to a PPS.

Journal ArticleDOI
TL;DR: In this paper, the authors present the results of the evaluation of the effectiveness of this program and evaluate the performance of the program in the city of Moscow, which is still a state-owned property this paper.