Showing papers in "Health Affairs in 1999"
TL;DR: The issue of informal caregiving is broadened from the micro level, where individual caregivers attempt to cope with the stresses and responsibilities of caregiving, to the macro level of the health care system, which must find more effective ways to support family caregivers.
Abstract: This study explores the current market value of the care provided by unpaid family members and friends to ill and disabled adults. Using large, national data sets we estimate that the national economic value of informal caregiving was $196 billion in 1997. This figure dwarfs national spending for formal home health care ($32 billion) and nursing home care ($83 billion). Estimates for five states also are presented. This study broadens the issue of informal caregiving from the micro level, where individual caregivers attempt to cope with the stresses and responsibilities of caregiving, to the macro level of the health care system, which must find more effective ways to support family caregivers.
681 citations
TL;DR: Depressed workers were found to have between 1.5 and 3.2 more short-term work-disability days in a thirty-day period than other workers, which suggests that encouraging depressed workers to obtain treatment might be cost-effective for some employers.
Abstract: We analyzed data from two national surveys to estimate the short-term work disability associated with thirty-day major depression. Depressed workers were found to have between 1.5 and 3.2 more short-term work-disability days in a thirty-day period than other workers had, with a salary-equivalent productivity loss averaging between $182 and $395. These workplace costs are nearly as large as the direct costs of successful depression treatment, which suggests that encouraging depressed workers to obtain treatment might be cost-effective for some employers.
410 citations
TL;DR: This paper presents data from surveys of about 1,000 adults conducted during April-June 1998 in each of five countries--Australia, Canada, New Zealand, the United Kingdom, and the United States--to measure public satisfaction with health care.
Abstract: Many nations have undergone changes in health care financing and services. The public notices policy changes in health care and frequently bears new and unexpected costs or barriers to care unwillingly. This paper presents data from surveys of about 1,000 adults conducted during April-June 1998 in each of five countries--Australia, Canada, New Zealand, the United Kingdom, and the United States--to measure public satisfaction with health care. In no nation is a majority content with the health care system. Different systems pose different problems: In systems with universal coverage, dissatisfaction is with the level of funding and administration, including queues. In the United States, the public is primarily concerned with financial access.
206 citations
TL;DR: The United States has the lowest percentage of the population with government-assured health insurance, and it also has the fewest hospital days per capita, the highest hospital expenditures per day, and substantially higher physician incomes than the other OECD countries.
Abstract: In 1997 the United States spent $3,925 per capita on health or 13.5 percent of gross domestic product (GDP), while the median Organization for Economic Cooperation and Development (OECD) country spent $1,728 or 7.5 percent. From 1990 to 1997 U.S. health spending per capita increased 4.3 percent per year, compared with the OECD median of 3.8 percent. The United States has the lowest percentage of the population with government-assured health insurance. It also has the fewest hospital days per capita, the highest hospital expenditures per day, and substantially higher physician incomes than the other OECD countries. On the available outcome measures, the United States is generally in the bottom half, and its relative ranking has been declining since 1960.
183 citations
TL;DR: Findings from the 1995 National Nursing Home Survey suggest that elderly Americans are reducing their use of nursing home care, and a change in the role of the nursing home, as defined in this survey.
Abstract: Findings from the 1995 National Nursing Home Survey suggest that elderly Americans are reducing their use of nursing home care. The numbers reflect a change in the role of the nursing home, as defined in this survey. By 1995 nursing facilities were increasingly focusing on patients with greater disability and postacute care needs. Preferred alternatives, most notably home-delivered care and assisted living, were likely filling the gap left by declining nursing home use. Better population-based studies are needed to track emerging trends and ascertain whether elders with disabilities are receiving the care they need. Such data could inform development of better public and private financing strategies for long-term care.
172 citations
TL;DR: It is concluded that reduction in spending growth creates measurable increases in health insurance coverage for low- Income workers and that the rapid increase in health care spending over the past fifteen years has created a large pool of low-income workers for whom health insurance is unaffordable.
Abstract: The decline in health insurance coverage among workers from 1979 to 1995 can be accounted for almost entirely by the fact that per capita health care spending rose much more rapidly than personal income during this time period. We simulate health insurance coverage levels for 1996-2005 under alternative assumptions concerning the rate of growth of spending. We conclude that reduction in spending growth creates measurable increases in health insurance coverage for low-income workers and that the rapid increase in health care spending over the past fifteen years has created a large pool of low-income workers for whom health insurance is unaffordable.
136 citations
TL;DR: In July 1998 the British National Health Service (NHS) marked its fiftieth anniversary by bringing together in one organization, for the first time, hospital, physician, and communit...
Abstract: PROLOGUE: In July 1998 the British National Health Service (NHS) marked its fiftieth anniversary. The NHS brought together in one organization, for the first time, hospital, physician, and communit...
135 citations
TL;DR: Managed care holds the promise of facilitating parity between general medical care and alcohol, drug, and mental health care by reducing expenditures, even while expanding benefits.
Abstract: Managed care holds the promise of facilitating parity between general medical care and alcohol, drug, and mental health care by reducing expenditures, even while expanding benefits. Limitations in our knowledge of variations in needs and treatment standards for substance use and psychiatric illnesses make such disorders an easy target for management. Costs for behavioral health care services have been reduced at a faster pace than has been the case for general medical care costs. The most severely ill face the potential burdens of managed care as access and intensity of care become more uniform across patient populations.
131 citations
TL;DR: In this paper, the effects of hospital restructuring and other health system changes on nurse staffing have been examined in both acute and non-acute care settings, and the authors found that nurses are working harder than ever, that work satisfaction and morale are suffering, and that the quality of patient care has deteriorated over the past few years.
Abstract: As managed care has spread across the country, registered nurses have felt the pinch in earnings and employment. Are changes on the horizon? P e t e r I. Bu e r h a u s a n d D o u g l a s O. S t a i g e r N u r s i n g p er s o n n el play a central role in producing and coordinating patient care in both acute and non-acute care settings, and recent vigorous efforts to lower and control costs have greatly affected nurses' employment, earnings, and clinical practice. Registered nurses (RNs), in particular, have been involved if reluctant participants in hospitals' efforts to restructure patient care delivery in the 1990s. Many RNs assert that they are working harder than ever, that work satisfaction and morale are suffering , and that the quality of patient care has deteriorated over the past few years. 1 They also complain that employment opportunities are disappearing rapidly in acute care hospitals , where historically two-thirds of all RNs have been employed. 2 The perceived decline in hospital employment has been balanced to some extent by the shift of patient care delivery into nonacute care settings. Many in the nursing profession believe that health care delivery has been overly concentrated in acute care settings and thus have welcomed this shift. 3 Moreover, the greater use of nonhospital settings has generated an expectation of new employment opportunities for nurses. Nursing education programs throughout the country are scrambling to revise their curricula to prepare nurses for new jobs and expanding opportunities in nonhospital settings. 4 However, some question the capacity of nonacute providers to employ all of the RNs leaving hospitals as a result of downsizing, consolidation , and efforts to gain greater efficiency. 5 These and many other problems besetting the nurse workforce were brought before the Institute of Medicine's (IOM's) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes in 1996 and the Presi-dent's Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998. 6 Throughout their deliberations , the committees faced a crucial lack of empirical data regarding the effects of hospital restructuring and other health system changes on nurse staffing. Thus, both committees called for public and private efforts to collect and analyze data on the nurse workforce. In our earlier work, …
131 citations
TL;DR: In this paper, the authors describe recent growth in age/sex-specific health care utilization by the elderly and discuss the important role of technology in that growth, and explore the potential for the elderly to pay for additional care through increases in work and savings, and conclude that efforts to save Medicare will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.
Abstract: Health care expenditures on the elderly tend to grow about 4 percent per year more rapidly than the gross domestic product (GDP). This could plunge the nation into a severe economic and social crisis within two decades. This paper describes recent growth in age/sex-specific health care utilization by the elderly and discusses the important role of technology in that growth. It also explores the potential for the elderly to pay for additional care through increases in work and savings. Efforts to "save Medicare" will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.
126 citations
TL;DR: It is determined that local practice leaders are able to implement predesigned interventions for improving depression care in managed care organizations based on evaluation of adherence to the intervention protocol.
Abstract: PROLOGUE: The gap between theory and practice in health care can be daunting. Researchers armed with massive amounts of outcomes data face the problem of translating their findings into workable interventions in the practice setting. This paper reports on an attempt to bridge the gap, taking advantage of the administrative capabilities of managed care organizations. The authors designed, implemented, and tracked a collaborative-care program of treatment for patients with symptoms of depression. The results presented here highlight the program's success in creating a “partnership between health care organizations and researchers.” Lisa Rubenstein is a practicing geriatrician and internist at the University of California, Los Angeles (UCLA), School of Medicine and Veterans Administration Medical Center (VAMC), Sepulveda, California; a senior natural scientist at RAND; and director of the VA/RAND/UCLA Center for the Study of Healthcare Provider Behavior. Maga Jackson-Triche is director of the Psychiatry Cons...
TL;DR: This paper examined the impact of Medicaid prescription drug copaymention policies in thirty-eight states using survey data from the 1992 Medicare Current Beneficiary Survey and found that elderly and disabled Medicaid recipients who reside in states with copay provisions have significantly lower rates of drug use than their counterparts in states without copayments.
Abstract: This DataWatch examines the impact of Medicaid prescription drug copayment policies in thirty-eight states using survey data from the 1992 Medicare Current Beneficiary Survey. Findings indicate that elderly and disabled Medicaid recipients who reside in states with copay provisions have significantly lower rates of drug use than their counterparts in states without copayments. After controlling for other factors, we find that the primary effect of copayments is to reduce the likelihood that Medicaid recipients fill any prescription during the year. This burden falls disproportionately on recipients in poor health.
TL;DR: Using data from the 1995 Medicare Current Beneficiary Survey (MCBS), the sources and extent of drug coverage among Medicare beneficiaries are described and a baseline to observe future changes in the level of coverage, particularly among Medicare managed care plans.
Abstract: Outpatient prescription drugs are not a covered benefit under Medicare. There have been proposals in the past to expand Medicare benefits to include drug coverage, and current discussions...
TL;DR: Canada's provincial Medicare systems cut inpatient care, expanded community services, and consolidated hospitals under regional authorities in nine of ten provinces in the 1990s, leaving the acute care sector badly shaken.
Abstract: Driven by fiscal pressures in the 1990s, Canada's provincial Medicare systems cut inpatient care, expanded community services, and consolidated hospitals under regional authorities in nine of ten provinces. Public confidence has been badly shaken by the transition. No province has successfully integrated services across the continuum of care. Home care and prescription drug coverage vary from province to province. Efforts to reform physician payment have stalled, and capacity to measure and manage the quality of care is generally underdeveloped. Thus, for the next few years, policymakers must stabilize the acute care sector, while cautiously pursuing an agenda of piece-meal reforms.
TL;DR: Japan's universal and egalitarian health care system helps to keep its population healthy at an exceptionally low cost and its financing and delivery systems have been adapted over the years in a gradual way that preserves balance.
Abstract: PROLOGUE: Japan's universal health care system, built on the German social insurance model and remarkably inexpensive by American standards, has nevertheless entered an era of economic stress and g...
TL;DR: Higher patient copayments for prescription drugs are associated with lower drug spending in IPA models but have little effect in network models, indicating that physicians bear financial risk for all prescribing behavior.
Abstract: This study estimates the impact of patient financial incentives on the use and cost of prescription drugs in the context of differing physician payment mechanisms A large data set was developed that covers persons in managed care who pay varying levels of cost sharing and whose physicians are compensated under two different models: independent practice association (IPA)-model and network-model health maintenance organizations (HMOs) Our results indicate that higher patient copayments for prescription drugs are associated with lower drug spending in IPA models (in which physicians are not at risk for drug costs) but have little effect in network models (in which physicians bear financial risk for all prescribing behavior)
TL;DR: This paper analyzes health spending, health outcomes, and health delivery system characteristics for the six developing regions of the world as well as for low-, medium-, and high-income country groupings.
Abstract: Developing countries account for 84 percent of world population and 93 percent of the worldwide burden of disease; however, they account for only 18 percent of global income and 11 percent of global health spending. Limited resources and administrative capacity coupled with strong underlying needs for services pose serious challenges to governments in the developing world. This paper analyzes health spending, health outcomes, and health delivery system characteristics for the six developing regions of the world as well as for low-, medium-, and high-income country groupings.
TL;DR: This study compares levels of satisfaction and autonomy among California physicians using data from a 1991 survey of physicians and a 1996 survey of California physicians to measure physicians' perceived freedom to undertake eight common activities that may be threatened by marketplace changes.
Abstract: This study compares levels of satisfaction and autonomy among California physicians using data from a 1991 survey of physicians and a 1996 survey of California physicians. The surveys measured physicians' perceived freedom to undertake eight common activities that may be threatened by marketplace changes, satisfaction with current practice, and inclination to attend medical school again. Young physicians in 1996 were significantly less likely to report that they were able to spend enough time on the eight identified patient-care activities. They also were significantly less satisfied with their current practice and less likely to say that they would go to medical school again. Satisfaction also declined for older physicians between 1991 and 1996.
TL;DR: Different patterns of change in the American, British, and Canadian health care systems in the 1990s result from the particular logic of each system, and different mixes of hierarchical, market-based, and collegial instruments create different incentives that shape behavior.
Abstract: Different patterns of change in the American, British, and Canadian health care systems in the 1990s result from the particular logic of each system. Different balances of influence across major categories of actors, and different mixes of hierarchical, market-based, and collegial instruments have different implications for lines of accountability and for information costs, and thus create different incentives that shape behavior. Market instruments functioned differently when introduced into Britain's system of "hierarchical corporatism" than in the American mixed-market system. Profession/state accommodations in Britain and Canada tempered the pace of change, while the entrepreneurial logic of the U.S. system generated a turbulent transformation.
TL;DR: This work proposes a method for using administrative data to develop a comprehensive assessment of value for mental health care, which it calls systems cost-effectiveness (SCE), and applies the method to acute-phase treatment of depression in a large insured population.
Abstract: The value of mental health services is regularly questioned in health policy debates. Although all health services are being asked to demonstrate their value, there are special concerns about this set of services because spending on mental health care has grown markedly over the past twenty years. We propose a method for using administrative data to develop a comprehensive assessment of value for mental health care, which we call systems cost-effectiveness (SCE). We apply the method to acute-phase treatment of depression in a large insured population. Our results show that SCE of treatment for depression has improved during the 1990s.
TL;DR: Employees who used mental health services showed a 37 percent increase in use of non-mental health services and significantly increased sick days, whereas other employees showed no such increases.
Abstract: This study examines concurrent changes in use of mental and general health services and in annual sick days among 20,814 employees of a large corporation. From 1993 to 1995 mental health service use and costs declined by more than one-third, more than three times as much as the decline in non-mental health service use. However, employees who used mental health services showed a 37 percent increase in use of non-mental health services and significantly increased sick days, whereas other employees showed no such increases. Savings in mental health services were fully offset by increased use of other services and lost workdays.
TL;DR: Public health policy could coordinate specialty and primary care to improve early detection and general medical care for persons with schizophrenia and promote evidence-based care.
Abstract: PROLOGUE: Schizophrenia, a chronic psychotic condition, has been highly misunderstood and stigmatized, both among medical professionals and in the general public, because of the disruptive and sometimes violent behavior associated with it Up until recently the drugs that were available to treat schizophrenia had such severe side effects that it was difficult to maintain compliance with a treatment regimen Recent advances in drug and other treatments, though, have improved patients' experiences with their therapies and have made it at least theoretically possible for them to return to more normal lives However, many patients still have not benefited from these advances, for a variety of reasons In 1992 the Agency for Health Care Policy and Research and the National Institute of Mental Health initiated the schizophrenia Patient Outcomes Research Team (PORT) project, whose treatment recommendations were issued in January 1998 These recommendations “provide a basis for moving toward ‘evidence-based’ prac
TL;DR: This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research in 1977, 1987, and 1996; and surveys of employers by the AHCPR and KPMG Peat Marwick/Kaiser Family Foundation in 1998.
Abstract: This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research (AHCPR) in 1977, 1987, and 1996; and surveys of employers by the AHCPR in 1977, by the Health Insurance Association of America in 1988, and by KPMG Peat Marwick/Kaiser Family Foundation in 1998. During the study years, in 1998 dollars, the cost of job-based insurance increased 2.6-fold, and employees' contributions for coverage increased 3.5-fold. The percentage of nonelderly Americans covered by job-based insurance plummeted from 71 percent to 64 percent. This decline occurred exclusively among non-college-educated Americans. An information-based global economy is likely to produce not only greater future wealth but also greater inequalities in income and health benefits.
TL;DR: Using two large employer health insurance surveys, this paper presents new estimates that both confirm and add to the understanding of changes taking place in employment-based health plans.
Abstract: PROLOGUE: John Maynard Keynes once quipped that “[p]ractical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist.” And ...
TL;DR: Hall as discussed by the authors describes the evolution of Australia's complex system and shows why, as long as public support and political momentum are divided between public and private financing, changes in health policy are likely to continue in increments.
Abstract: PROLOGUE: Although Australians have entertained no major health care reforms since the implementation of universal health insurance in 1984, the past fifteen years have hardly been quiet ones for Australian health policy. Under a multilevel system of government and with a combination of public and private financing, the country has struggled to maintain its long-held and often-tested commitment to universal access to health care. Efforts to defend the national insurance program have been matched repeatedly by challenges, but support for a greater role for private insurance, although persistent, has been slow to gather strength. As a result, the system moves forward in fits and starts, fending off major change in favor of incremental reforms. In this paper Jane Hall describes the evolution of Australia's complex system and shows why, as long as public support and political momentum are divided between public and private financing, changes in health policy are likely to continue in increments. Fortunately, ...
TL;DR: It is concluded that although efficient large-group insurance will appropriately continue to exist, the individual market appears to be improving, in both administrative cost and protection against high premiums associated with high risk.
Abstract: PROLOGUE: In a system dominated by private group health insurance, individual coverage has never been a very attractive option for most people. Indeed, for several reasons, less than 7 percent of the population obtains nongroup health insurance. It's unaffordable for many people—in part because of very high administrative costs—and it may be difficult to obtain for some persons who have preexisting medical conditions. But as policymakers search for other private-sector alternatives to job-based group coverage, options once considered less attractive—particularly when government-sponsored or -administered solutions to broadened coverage held greater political appeal—are emerging as possible approaches. In this paper Mark Pauly and his colleagues at the University of Pennsylvania's Wharton School discuss how individual insurance could be improved and thus made more attractive to more prospective buyers. Pauly, a leading health economist who believes in market-based solutions to problems of insurance coverag...
TL;DR: It was found that states with below-average utilization were more likely to enact state legislation, but utilization in those states continues to lag behind the rest of the nation.
Abstract: A new wave of state and federal legislation affecting mental health insurance was passed during the 1990s. Although patient advocacy groups have hailed the passage of numerous parity laws...
TL;DR: It is shown that nonprofit and government hospitals have steadily become more willing to raise prices to exploit market power and discuss the implications for antitrust regulators and agencies that must approve nonprofit conversions.
Abstract: Dramatic changes in hospitals’ operating environments are leading to major restructuring of hospital organizations. Hospital mergers and acquisitions are increasing each year, and convers...
TL;DR: Comparisons with data from 1996 show that the proportion of plans with benefits for "alternative" types of MH/SA services, such as nonhospital residential care, has increased, and the proportion with special limitations on these benefits shows a modest decrease.
Abstract: PROLOGUE: Concerns over disparities in the level of insurance coverage for mental health and substance abuse (MH/SA) treatment compared with general medical coverage were partly responsible for the Mental Health Parity Act of 1996, which took effect last year. In addition, fourteen states have passed legislation that goes beyond the requirements of the federal parity act. To track behavioral health care benefits in employer-sponsored insurance, researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA) worked with employer survey experts from William Mercer to analyze questions on MH/SA benefits from the Mercer/Foster Higgins National Survey of Employer-Sponsored Health Plans. This paper represents the second publication of survey results in Health Affairs ; the first round appeared in July/August 1997. The authors found some improvement in benefits between 1996 and 1997. However, it is too early to tell if this improvement represents a permanent reversal in general terms. Jef...