Showing papers in "Inquiry in 2002"
TL;DR: It is found that nursing homes located in urban areas have markets that are a fraction of the size of the county in which they are located, and the Herfindahl-Hirschman Index (HHI) is calculated to measure the competitiveness of each nursing home's market.
Abstract: Previous studies of nursing home markets have assumed that a nursing home's market is coincident with the boundaries of the county in which it is located. We test this assumption by using the zip c...
73 citations
TL;DR: The results indicate that, in both 1986 and 1991, mean inefficiency was highest for for-profits and lowest for not-for-profit hospitals, with government hospitals falling in the middle.
Abstract: This study examines how ownership affected changes in hospital inefficiency after the introduction of prospective payment by Medicare. Using a national data set, we estimate cost frontiers for 1986 and 1991 to assess hospitals' efficiency relative to best practice in both those years. We then use regression analysis to determine the effect of ownership on the change in hospitals' efficiency. The results indicate that, in both 1986 and 1991, mean inefficiency was highest for for-profit hospitals and lowest for not-for-profit hospitals, with government hospitals falling in the middle. Moreover, between 1986 and 1991, both for-profit and government hospitals had significantly less improvement in efficiency than not-for-profit hospitals, all else equal.
58 citations
TL;DR: The results show that mandatory health maintenance organization (HMO) programs have had a positive impact on both children and adults, particularly when compared to Medicaid fee-for-service plans.
Abstract: This paper uses data from the 1997 National Survey of America's Families to examine the effects of the various forms of mandatory Medicaid managed care on access and use among beneficiaries not receiving Supplemental Security Income or Medicare benefits. The results show that mandatory health maintenance organization (HMO) programs have had a positive impact on both children and adults, particularly when compared to Medicaid fee-for-service plans. We observed less dependence on emergency rooms as a usual source of care, a greater probability of visiting a doctor and, for children, greater use of preventive care. In contrast, mandatory primary care case management plans (PCCM) provided some benefits to children, but appeared to have very little impact on adult Medicaid beneficiaries. Mandatory programs that use both HMOs and PCCM produced mixed results. With the exception of mandatory HMO programs, discrepancies in access and use continue to exist between Medicaid managed care enrollees and low-income priv...
47 citations
TL;DR: Findings show that offer decisions reflect worker demand, labor market conditions, and establishments' costs of providing coverage, and premiums have a moderate effect on offer decisions, suggesting that premium subsidies to employers would be an inefficient means of increasing insurance coverage.
Abstract: This paper explores the decisions by small business establishments (less than 100 workers) to offer health insurance We estimate a theoretically derived model of establishments? demand for insurance using nationally representative data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey and other sources Findings show that premiums have a moderate effect on offer decisions (elasticity = -54), though very small establishments and those employing low-wage workers are more responsive This suggests that premium subsidies to employers would be an inefficient means of increasing insurance coverage Greater availability of public insurance and safety net care has a small negative effect on offer decisions (Inquiry 2002 Summer; 39: 118-137)
39 citations
TL;DR: A simple, straightforward adjustment method is presented that can be applied to the 1987 NMES public use expenditure data to improve comparability to the MEPS and presents several examples of the application that illustrate the importance of the adjustments for analyses of trends in health care spending.
Abstract: Substantial changes in the organization, delivery, and financing of health care over the last decade, combined with data collection and methodological improvements in the 1996 Medical Expenditure P...
28 citations
TL;DR: The results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.
Abstract: In recent years, there has been large growth in the nursing home industry in the use of case-mix adjusted Medicaid payment systems that employ resident characteristics to predict the relative use of resources in setting payment levels. Little attention has been paid to the access and quality incentives that these systems provide in the presence of excess demand conditions due to certificate-of-need (CON) and construction moratoria. Using 1991 to 1998 panel data for all certified U.S. nursing homes, a fixed-effects model indicates that adoption of a case-mix payment system led to increased access for more dependent residents, but the effect was modified in excess demand markets. Quality remained relatively stable with the introduction of case-mix reimbursement, regardless of the presence of excess demand conditions. These results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.
25 citations
TL;DR: Findings show that adverse selection is not a problem in voluntary public programs, and the challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.
Abstract: This paper examines how varying the level of subsidies affects participation in a public insurance program, crowd-out of private insurance, and adverse selection. We study the experience in Washington's Basic Health program in 1997. Findings show that adverse selection is not a problem in voluntary public programs. Increasing subsidies have only modest effects on participation in subsidized programs, though the gains are not at the expense of the private market. Overall participation in the subsidized plan is also modest, even though participants benefit from it. The challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.
23 citations
TL;DR: Estimates and predictions are not sensitive to the modeling approaches chosen, although the ZINB model outperforms the two-part models in terms of out-of-sample prediction.
Abstract: Studies attempting to project the impact of providing health coverage to the uninsured population have demonstrated considerable variation in the estimated costs of mental health care. Different modeling approaches to project health care use and costs have been shown to address some data characteristics well, but not all of them. Using data from Health Care for Communities, a recent national household survey, this paper attempts to estimate and predict the use of mental health outpatient services if insurance coverage were extended to the uninsured. The study employs two-part models, with the second part based on an ordinary least squares (OLS) approach and a generalized linear model (GLM), and a zero-inflated negative binomial model (ZINB). Estimates and predictions are not sensitive to the modeling approaches chosen, although the ZINB model outperforms the two-part models in terms of out-ofsample prediction.
23 citations
TL;DR: Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality.
Abstract: This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing informat...
23 citations
TL;DR: Analysis of the effects of different insurance product designs on service use, access, and consumer assessments of care for nonelderly people with employer-sponsored insurance finds no evidence of differences across product types in unmet need or delayed care or use of hospitals, surgery, or emergency rooms.
Abstract: This paper uses 1996–97 Community Tracking Study data to analyze the effects of different insurance product designs on service use, access, and consumer assessments of care for nonelderly people wi...
22 citations
TL;DR: Risk selection among competing Medicare managed care plans is quantified, using beneficiary survey data from the Consumer Assessments of Health Plans Survey®, indicating that the selection was driven by plan attributes.
Abstract: This paper quantifies risk selection among competing Medicare managed care plans, using beneficiary survey data from the Consumer Assessments of Health Plans Surveyt. Selection, measured by variation in plan-level prevalence of health conditions and predicted costs, was substantial. A plan with moderate (one standard deviation) adverse selection would have predicted costs 11.6% above an average plan. Only a small part of this variation was explained by the geographical differences in the prevalence of health conditions among or within Metropolitan Statistical Areas, indicating that the selection was driven by plan attributes. Plans serving members with greater health needs have the potential to establish programs to serve these sick members well, yet this places plans at financial risk. Hence, improved risk adjustment for chronic conditions may be warranted. Moreover, survey measures have the potential to measure the prevalence of such conditions reliably and consistently across plans.
TL;DR: It is found that HMOs' provider networks with physicians, hospitals, skilled nursing homes, and home health agencies are complex and multi-tiered and the complex layering of risk sharing and delegation of care management responsibility raise questions about accountability and administrative costs in managed care.
Abstract: The transfer of financial risk from health maintenance organizations (HMOs) to providers is controversial. To provide timely national data on these practices, we conducted a telephone survey in 1999 of a multi-staged probability sample of HMOs in 20 of the nation's 60 largest markets, accounting for 86% of all HMO enrollees nationally. Among those sampled, 82% responded. We found that HMOs' provider networks with physicians, hospitals, skilled nursing homes, and home health agencies are complex and multi-tiered. Seventy-six percent of HMOs in our study use contracts for their HMO products that involve global, professional services, or hospital risk capitation to intermediate entities. These arrangements account for between 24.5 million and 27.4 million of the 55.9 million commercial and Medicare HMO enrollees in the 60 largest markets. While capitation arrangements are particularly common in California, they are more common elsewhere than many assume. The complex layering of risk sharing and delegation of...
TL;DR: It is concluded that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.
Abstract: Declining welfare caseloads may lead to a sicker population remaining in the Medicaid program, which could increase per enrollee costs and the level of adequate capitation rates. Using data from the 1997 National Survey of America's Families for adults and children, we examine differences in health status and utilization among welfare recipients and welfare leavers who did and did not retain Medicaid. We adjust utilization differences for insurance status and factors often used to adjust capitation rates. We conclude that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.
TL;DR: It is found that hospital advertising in California increased dramatically: annual spending on advertising grew (inflation adjusted) more than sixfold over the period, and advertising expenditures varied significantly across hospitals.
Abstract: This paper examines the advertising behavior of California hospitals from 1991 to 1997. Using highly detailed hospital-level information, we found that hospital advertising in California increased dramatically: annual spending on advertising grew (inflation adjusted) more than sixfold over the period. In addition, advertising expenditures varied significantly across hospitals. We found that hospital advertising increased with market concentration; with the number of nearby potential patients; with the percentage of nearby patients insured through Medicare, health maintenance organizations (HMOs), and indemnity insurance; and with chain affiliation. For-profit hospitals were not found to advertise more than their not-for-profit counterparts.
TL;DR: It is concluded that the trade-off between productivity and teaching is more serious in primary care than in inpatient settings, and that facilities heavily involved in ambulatory care teaching will be at a competitive disadvantage if GME subsidies are not targeted specifically for primary care.
Abstract: This paper examines the indirect costs of primary care residency in terms of ambulatory care site productivity and the influence of graduate medical education (GME) subsidies on the employment of primary care residents Using a sample of hospitals and health centers in New York City (NYC), we find that most facilities employ significantly more primary care residents relative to nonresident primary care physicians than would be dictated by cost-minimizing behavior in the production of primary care We also find evidence that New York’s GME subsidy encourages the ‘‘overemployment’’ of residents, while the Medicare GME subsidy does not We conclude that the trade-off between productivity and teaching is more serious in primary care than in inpatient settings, and that facilities heavily involved in ambulatory care teaching will be at a competitive disadvantage if GME subsidies are not targeted specifically for primary care
TL;DR: In this paper, the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare, was assessed.
Abstract: The issue of risk selection is especially important for states that enroll blind and disabled beneficiaries of Supplemental Security Income (SSI) in Medicaid managed care. SSI beneficiaries have persistent needs for care, have a wide variety of chronic conditions, and often need atypical and complex services. Risk selection occurs when the health care needs of beneficiaries enrolled in a specific plan differ systematically from the needs of the overall beneficiary population and payments do not reflect those needs. We assess the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare. Using claims data containing fee-for-service expenditures prior to enrollment in managed care, we find substantial evidence of persistent risk selection among plans. Results are robust to most alternative measures of risk selection for most plans.
TL;DR: Health system leaders must find compelling reasons to assume corporate citizenship roles and learn how to play citizenship roles more fully and effectively if the potential social good available through health systems' corporate citizenship is to be realized.
Abstract: Leading nonprofit health systems are demonstrating that communities can benefit from the emergence of this new class of corporate citizens. Just as the business sector has produced many good corporate citizens to the great advantage of American society, health systems with sufficient financial and organizational gravitas increasingly are assuming these roles, and in so doing, are making positive differences in their communities. More system leaders, however, must find compelling reasons to assume these demanding roles. They also must learn how to play citizenship roles more fully and effectively if the potential social good available through health systems' corporate citizenship is to be realized.
TL;DR: Overall, there is no evidence of adverse selection into more generous plans for alcohol treatment services, and treatment costs of new members compared to old members are lower in firms with more generous treatment benefits than in companies with more limited benefits.
Abstract: Concerns about attracting disproportionate numbers of employees with alcohol problems limit employers' willingness to offer health plans with generous alcohol treatment benefits. This paper analyzes two potential avenues of adverse selection, namely biased enrollment into plans and biased exit from plans offered by 57 employers between 1991 and 1997. We compare alcohol treatment use rates and costs of new and old enrollees between more generous and less generous plans; we also analyze disenrollment rates and enrollment duration by plan generosity for users and nonusers of alcohol treatment services. To avoid confounding benefit generosity with other plan features, in particular the use of managed care mechanisms, we compare plans that were administered in the same way by a large managed behavioral health care organization. Overall, we find no evidence of adverse selection into more generous plans. Contrary to the selection hypothesis, treatment costs of new members compared to old members are lower in fir...
TL;DR: This article comes out of a series of discussions among a diverse group of chief executive officers (CEOs) and other leaders of nonprofit hospitals, long-term care facilities, health maintenance organizations, and other insurance providers, including several nonprofit Blue Cross Blue Shield (BCBS) plans.
Abstract: This article comes out of a series of discussions among a diverse group of chief executive officers (CEOs) and other leaders of nonprofit hospitals, long-term care facilities, health maintenance organizations, and other insurance providers, including several nonprofit Blue Cross Blue Shield (BCBS) plans. The group was convened as part of Howard Berman's Walter J. McNerney Fellowship project. (Berman is CEO of Excellus, Inc., a nonprofit Blue Cross Blue Shield affiliate that insures the health of more than 2.15 million people in upstate New York. He was awarded the McNerney Fellowship in April 2001 by the Health Research and Educational Trust, an American Hospital Association affiliate. The Fellowship goes annually to at least one fellow to highlight or pursue work that will provide new insights into how different sectors of the health care system can better work together for improved outcomes.) The group has met several times over the past year around a shared concern: the current challenges to nonprofit health care organizations and the future role for nonprofits in the re-visioning and creation of an American health care system that is characterized by universal access, patient-centered quality, and national affordability. Members have supported the public relations campaign of the "Alliance for Advancing Nonprofit Health Care," an effort initiated by the Caucus, an independent group of nonprofit BCBS plans. The group continues to explore the need for a broad-based coalition of providers, insurers, and other organizations to effectively protect and enhance the role of nonprofit health care.
TL;DR: The values that have always driven health care management and how those values can be used to confront today's challenges are outlined and promises are made to build upon those values.
Abstract: Originally presented as an endowed lecture, this paper outlines the values that have always driven health care management and how those values can be used to confront today's challenges. The challenges are discussed in a way that clearly calls for promises to build upon the values that will improve the health care environment and the obligations that health care managers have to fulfill those promises.
TL;DR: This column explores the dynamics of boards, the connections among the three sectors, and the nation's growing reliance on nonprofits.
Abstract: Nonprofit organizations play a unique role in American life. However, they cannot exist alone; they have a complex, interdependent relationship with the economy's two other sectors—business and gov...