Showing papers in "Inquiry in 2004"
TL;DR: It is found that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality.
Abstract: Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon ' s quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.
115 citations
TL;DR: The findings of this study confirm that public policies and community environment have measurable and substantial impacts on access to care, and that expanded public resources can lead to measurable improvements in access for vulnerable populations residing in large urban areas.
Abstract: This study examines the effects of community-level and individual-level factors on access to ambulatory care for lower-income adults in 54 urban metropolitan statistical areas in the United States....
69 citations
TL;DR: Findings indicate that clinical events resulting in claims that lead to substantial indemnity payments have a significant, modest effect on physician practice behavior: physicians experiencing those claims increase their risk-adjusted cesarean rates by about one percentage point.
Abstract: This study examines the influence of malpractice claims on the practice behavior of a panel of obstetricians in Florida during the period 1992-1995 to determine whether physicians respond to malpractice events by performing more cesareans, consistent with the notion that cesarean sections are employed as "defensive medicine." Findings indicate that clinical events resulting in claims that lead to substantial indemnity payments have a significant, modest effect on physician practice behavior: physicians experiencing those claims increase their risk-adjusted cesarean rates by about one percentage point. Malpractice experience does not appear to affect patient mix, but claims with large payouts may affect patient volume.
69 citations
TL;DR: It was found that some operational changes instituted by hospitals facing financial pressures from the BBA were similar to those observed for hospitals that faced pressure from Medicare PPS, including efforts to contain Medicare cost growth, to expand outpatient service provision, and to contain hospital staffing.
Abstract: The Balanced Budget Act (BBA) of 1997 initiated several changes to Medicare payment policy in an effort to slow the growth of hospital Medicare payments and ensure the future of the Medicare Hospital Insurance Trust Fund. Although subsequent federal legislation relaxed some original proposals, restored funds were limited and directed to specific types of hospitals. In addition, these Medicare policy changes came at a time when hospitals faced private sector payment constraints. This paper assesses the short-term effects of the BBA on operations of nonprofit hospitals in the United States and compares these effects to those observed in the early 1980s during implementation of the Medicare prospective payment system (PPS). We found that some operational changes instituted by hospitals facing financial pressures from the BBA were similar to those observed for hospitals that faced pressure from Medicare PPS, including efforts to contain Medicare cost growth, to expand outpatient service provision, and to cont...
51 citations
TL;DR: A Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics is presented, finding that hospital-based facilities are 600% more likely to close than are free-standing homes.
Abstract: This paper draws from a rich longitudinal California data set to analyze the scope and nature of nursing home closures between 1997 and 2001, and to present a Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics. When compared with the sample total of 1,482 facilities operating in the baseline year of 1997, only 56 facilities closed through 2001, involving the loss of 3.8% of facilities and 2,915 beds (2.3%). The multivariate Cox model of factors associated with closure reports that: 1) hospital-based facilities are 600% more likely to close than are free-standing homes; 2) reducing bed size by one standard deviation (52 beds) increases the risk of closure by 460%; 3) facilities with losses of 5% or worse are more than twice as likely to close; and 4) a one-standard deviation increase in the spare bed capacity measure of county competition raises the risk of facility closure by 140%.
33 citations
TL;DR: All but one methodology explained at least 50% of panel cost variance with panels as small as 25 patients, and Group R 2 performance tended to be better when high-cost cases were included rather than excluded from the analyses.
Abstract: This paper examines the relative accuracy of risk-adjustment methodologies used to profile primary care physician practice efficiency. Claims and membership data from an independent practice association health maintenance organization (HMO) were processed through risk-adjustment software of six different profiling methodologies. The Group R2 statistic was used to measure, for simulated panels of HMO members, how closely each methodology's cost predictions matched the panel's actual costs. All but one methodology explained at least 50% of panel cost variance with panels as small as 25 patients. Group R2 performance tended to be better when high-cost cases were included rather than excluded from the analyses.
27 citations
TL;DR: Examination of trends in HMO enrollment in all metropolitan communities from 1994 to 2000 finds the backlash is not evidenced in a large degree of consumer switching, and HMOs were more likely to maintain their presence in areas with high-cost growth and with greater managed care experience.
Abstract: The managed care backlash led many to predict the demise of health maintenance organizations (HMOs). This paper examines trends in HMO enrollment in all metropolitan communities from 1994 to 2000 to identify factors that led to diminishing enrollment in the backlash era and circumstances in which HMOs maintained or expanded their presence. We use a database constructed from a wide variety of sources that describe HMO penetration and other characteristics of all metropolitan statistical areas. We found the backlash is not evidenced in a large degree of consumer switching. However, HMOs were more likely to maintain their presence in areas with high-cost growth and with greater managed care experience. Medicaid HMO growth continued to expand rapidly, indicating the possibility of a two-tiered system in which low-income beneficiaries have less choice than the privately insured.
25 citations
TL;DR: In this article, the authors examined price discounting by health maintenance organizations (HMOs) and preferred provider organizations (PPOs) in markets for hospital services and found that on average angioplasty prices are 8% lower for PPOs than for fee-for-service plans, followed by point-of-service HMOs, which capture a 24% discount.
Abstract: The paper examines price discounting by health maintenance organizations (HMOs) and preferred provider organizations (PPOs) in markets for hospital services. Our empirical analysis focuses on transaction prices for angioplasty, which is a relatively common procedure with well-defined ‘‘product’’ characteristics. After controlling for patient and procedure heterogeneity and market power, we find that on average angioplasty prices are 8% lower for PPOs than for fee-for-service plans, followed by point-of-service HMOs, which capture a 24% discount. Our results are in general agreement with earlier work by Cutler, McClellan, and Newhouse (2000), who show that managed care discounts are ‘‘real,’’ after accounting for case severity and process of care. It is generally assumed that managed care has been successful at lowering prices, but the implications have been a matter of debate. Critics have argued that managed care organizations attain savings by reducing intensity of services; others have argued that savings are ‘‘real’’ and are a consequence of discounts per unit of care, rather than a consequence of reduced intensity. Examining treatment episodes for acute myocardial infarctions (i.e., heart attacks), Cutler, McClellan, and Newhouse (2000) suggest that discounts are attained by managed care plans without sacrificing intensity. They pose the question, ‘‘Does managed care achieve discounts through reduced intensity?’’ We rephrase the question as, ‘‘Does managed care achieve discounts even after accounting for product heterogeneity?’’ To address this, we use a unique claims database that contains relatively rich detail on both sources of payment and on the process of care for hospital procedures. The specific procedure that we focus on is angioplasty, which is suitable for empirical research because it is a well-defined and relatively common cardiac procedure. Our study complements Cutler, McClellan, and Newhouse in one other important dimension: their study examined differences among managed care options within a single large health maintenance organization (HMO), whereas we focus on differences among various insurers and employers. After accounting for market forces, case mix, and product heterogeneity, we
21 citations
TL;DR: Findings from a national survey of physicians working in the emerging career of hospital medicine find that female hospitalists earn significantly less annually than male hospitalists, despite similar work schedules and commitments.
Abstract: This study presents findings from a national survey of physicians working in the emerging career of hospital medicine. It finds that female hospitalists earn significantly less annually than male hospitalists, despite similar work schedules and commitments; that these similarities in work and differences in pay remain even for male and female hospitalists who are married and have children; and that female hospitalists maintain positive feelings toward their work careers despite assuming multiple work and nonwork roles simultaneously. The results present a unique picture of female physicians' career experiences in toto. They have implications for how health care organizations and managers should think about the contemporary female physician (e.g., her career development needs and workplace challenges);for female physicians' need to gain greater equity vis-a-vis men within the profession; and for the kinds of questions researchers should raise around physician gender in their work.
20 citations
TL;DR: Results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.
Abstract: This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina)...
19 citations
TL;DR: Cost-sharing payments fell in six of the nine states following the BBA, and access to outpatient physician visits for dually eligible beneficiaries was reduced relative to non-dually eligible beneficiaries in those states.
Abstract: The Balanced Budget Act (BBA) of 1997 allowed states to limit how much their Medicaid programs contributed toward the Medicare cost-sharing liability of dually eligible beneficiaries. Policymakers have grown concerned that such limitations may affect access to care for these beneficiaries. We used a quasi-experimental design to analyze changes in access from 1996 to 1998, using Medicare and Medicaid data from nine states. Cost-sharing payments fell in six of the nine states following the BBA, and access to outpatient physician visits for dually eligible beneficiaries was reduced relative to non-dually eligible beneficiaries in those states.
TL;DR: This work estimated how managed care market share varied with the proportion of fee-for-service Medicare beneficiaries who were admitted for acute myocardial infarction and underwent angiography, and classified patients as appropriate, discretionary, and inappropriate.
Abstract: Evidence suggests that when managed care market share increases in a geographic area, expenditures in Medicare's fee-for-service sector decrease. But it is unclear how expenditure reductions relate to the quality of medical care for traditional Medicare beneficiaries. We estimated how managed care market share varied with the proportion of fee-for-service Medicare beneficiaries who were admitted for acute myocardial infarction (AMI) and underwent angiography. We classified patients as appropriate, discretionary, and inappropriate, according to guidelines of the American College of Cardiology and the American Heart Association (ACC-AHA). Within all ACC-AHA classes, coronary angiography fell slightly as managed care market share increased.
TL;DR: This analysis finds that although HIPAA has only a limited effect on current e-prescribing practices, future electronic prescribing systems will likely fall short of their potential benefits, absent policy refinements designed to encourage clinically appropriate, networked sharing of patient health information.
Abstract: Electronic prescribing offers the prospect of safer medication management, but fulfillment of that promise depends on ready access to personal health information from many sources, thus raising new concerns about information privacy and security. Federal privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) limit the sharing of health information by providers, and particularly may discourage information sharing over distributed computer networks. This analysis finds that although HIPAA has only a limited effect on current e-prescribing practices, future electronic prescribing systems will likely fall short of their potential benefits, absent policy refinements designed to encourage clinically appropriate, networked sharing of patient health information.
TL;DR: Examination of factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month suggests that enrollee satisfaction depends on the cultural competence of providers.
Abstract: Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.
TL;DR: The causes and implications of this sea change in nonprofit governance are explained and five success factors that the senior management of nonprofits can apply to improve board performance are presented.
Abstract: During the past two decades, our nation's nonprofit sector has undergone a tremendous increase in size and complexity causing a sea change in nonprofit governance. Today's standard of performance expected of trustees in nonprofits is much higher than it once was. Yet many trustees do not possess a clear understanding of their role, thus jeopardizing the future of nonprofits. This paper explains the causes and implications of this sea change in nonprofit governance and presents five success factors that the senior management of nonprofits can apply to improve board performance.
TL;DR: Conurrent diagnosis-based risk adjustment and a hybrid using concurrent adjustment for about 8% of the cases and prospective adjustment for the rest, perform markedly better than prospective or demographic adjustments, both in terms of R2 and the extent to which plans experience unwarranted gains or losses.
Abstract: Various approaches have been proposed to adjust for differences in enrollee risk in health plans Because risk-selection strategies may have different effects on enrollment, we simulated three types of selection--dumping, skimming, and stinting Concurrent diagnosis-based risk adjustment, and a hybrid using concurrent adjustment for about 8% of the cases and prospective adjustment for the rest, perform markedly better than prospective or demographic adjustments, both in terms of R2 and the extent to which plans experience unwarranted gains or losses The simulation approach offers a valuable tool for analysts in assessing various risk-adjustment strategies under different selection situations
TL;DR: It is found that focusing on small employers and the nongroup market could target government spending where costs are highest and insurance markets most unstable.
Abstract: This paper analyzes the potential effects of alternative government reinsurance mechanisms on public and private expenditures in group and nongroup health insurance markets. High reinsurance thresholds, with the government taking responsibility for costs over $50,000 per year, would absorb a small share of private costs. Lower thresholds would have greater effects, but would increase government costs significantly. We also find that reinsurance would reduce the variance in expenditures considerably and should reduce risk premiums charged by private insurers. We conclude that focusing on small employers and the nongroup market could target government spending where costs are highest and insurance markets most unstable. (Blumberg, Linda and Holahan, John. Summer 2004. Government as Reinsurer: Potential Impacts on Public and Private Spending. Inquiry 41: 130-143.)
TL;DR: This study shows that for-profit health plans do act differently than not-for-profit plans in terms of performance, efficiency, and contribution to safety net programs, and suggests that not- for- Profit health insurers operating in a predominantly for- profit market act in many ways like for-profits.
Abstract: Following on the heels of the first national study demonstrating differences in the community benefits provided by not-for-profit and for-profit health maintenance organizations (HMOs) (Schlesinger...
TL;DR: The Bush administration is providing the same message with the call that the authors create an ‘‘ownership society’’, where risks of breakage are to be shifted from society at large to their individual shoulders.
Abstract: If you’ve ever been in a store with pottery or glassware, you know the signs: ‘‘You break it, you own it.’’ Such signs clearly indicate that the risk of breakage is on your shoulders and the shopowner will not share the risk. The Bush administration is providing the same message with the call that we create an ‘‘ownership society.’’ The president wants us to take greater responsibility for our own lives. What is left unsaid is that risks of breakage are to be shifted from society at large to our individual shoulders. If only the costs of back injuries or torn rotator cuffs or a very long list of other medical concerns were on a par with the costs of breaking a teacup in a china shop! Most of us then could afford the risks of such medical costs. But analyses of data from the 1996 Medical Expenditure Panel Survey (MEPS) indicate that one in 10 Americans had medical expenses above $4,225 in 1996, and those in this group under age 65 had average expenses of about $11,000 (Monheit 2003; Berk and Monheit 2001). Accounting for price inflation and changes in the practice of medicine since 1996, a person among today’s top 10% of health care spenders probably has expenses exceeding $6,000, with average expenses for a person in this group around $15,000. At least half the population in the United States cannot possibly save enough money in one year to cover these costs of medical care.
TL;DR: The results show that HMOs manage claims payable with a multi-period perspective designed to evoke favorable responses and to avoid unfavorable ones from external parties, and to maintain flexibility for unexpected conditions.
Abstract: This paper used financial data from health maintenance organizations (HMOs) in the United States from the period 1985 to 2001 to examine the determinants of claims payable--the dollar amount of services rendered to enrollees but for which the HMO has not yet paid providers, such as physicians and hospitals. Claims payable management is important because delaying payments to providers can jeopardize provider operations and reduce HMO operational flexibility. The results show that HMOs manage claims payable with a multi-period perspective designed to evoke favorable responses and to avoid unfavorable ones from external parties, and to maintain flexibility for unexpected conditions. Higher HMO profitability, quicker receipt of premiums by the HMO, increased provider involvement, and greater local control of the HMO lead to faster payment to providers. Implications for HMO managers, providers, employers, and regulators are discussed.
TL;DR: This paper outlines a six-point management program designed to increase the income and decrease the expense currently associated with uncompensated care, while improving quality, patient satisfaction, and outcomes.
Abstract: As more people lose their health insurance, an increasing volume of uncompensated care is absorbing billions of dollars of limited resources of the nation's hospitals, health systems, and other provider organizations. As yet, no provider organization has developed a comprehensive management approach to address this growing problem. Currently, the money spent on uncompensated care is viewed as a drain on institutional bottom lines rather than as a fund dedicated to improving the health of uninsured patients and prospective patients. If an accountable executive were made responsible for managing this problem by paying for all of this care on a case-by-case basis as third parties do, uncompensated care could be eliminated. Payment for each case would come from the institutional resources no longer required for uncompensated care. There is reason to hypothesize that with effective management, a significant amount of the resources currently absorbed by uncompensated care could be shifted from excessive inpatie...
TL;DR: This article presents lessons for other states and all types of nonprofit health care organizations from the failure by nonprofit CareFirst Blue Cross Blue Shield to convert to for-profit status and be sold to the publicly traded Wellpoint Health Networks, Inc.
Abstract: This article presents lessons for other states and all types of nonprofit health care organizations from the failure by nonprofit CareFirst Blue Cross Blue Shield to convert to for-profit status and be sold to the publicly traded Wellpoint Health Networks, Inc. The lessons relate only in part to conversions. More broadly they concern any kind of strategic decision making by nonprofit health care boards of directors and their executives that substantially affects the public interest. This article is a companion to one by this same author published in the Fall 2004 issue of Inquiry. That article chronicled the events and political environment surrounding the conversion proposal, the review process and decision, and the aftermath of actions and reactions by various parties, including state legislation to clarify CareFirst's mission and to reform its board.
TL;DR: The book is an excellent example of the role of cases studies as the bedrock of social science theory building and of the complexity of transferring the lessons learned in Europe to less developed countries.
Abstract: economic—whichisbothastrengthandweakness. It lacks grounding in the managerial realities of making a hospital or hospital system work. The same limitation applies to the chapter by Mead Over and Naoko Watanabe, ‘‘Evaluating the Impact of Organizational Reforms in Hospitals.’’ The chapter by Chris Ham and Loraine Hawkins, ‘‘Implementing Organizational Reforms to Hospitals in the Public Sector,’’ provides some of the needed confrontation with the realities of management that the economists underestimate. They map the values, centers of power, and actors that make or break the best intentions of would-be reformers. If read together with Ham’s examination of the recent vicissitudes of the National Health Service (in the case studies section of the book), one must conclude that the role (i.e., capacity, competencies, values, accountabilities) of public sector managers at all levels is a variable of tremendous importance to this discussion— and a subject that merits more direct attention. Both chapters also demonstrate the complexity of transferring the lessons learned in Europe to less developed countries, the objective of including them in the book. Parts two and three consist of case studies and commentary. The cases are interesting but uneven in their contribution to the objective of the book. One problem is that the selection obscures the important distinction between countries that have relatively strong public and private sector infrastructures and those that do not. The former cases include the United Kingdom, New Zealand, Australia, Hong Kong and Singapore, none of which are bank clients. Arguably, the likelihood of moving a reform agenda in such places is a different task than it is in World Bank client countries such as Malaysia, Tunisia, Indonesia, and Ecuador, the other case study countries. The differences on the indices of corruption and transparency alone make the distinction clear. The book is an excellent example of the role of cases studies as the bedrock of social science theory building. Cases explore new or unknown social phenomena to identify the variables that then may be systematically researched to test, refine, and build theories that explain the phenomena, and to predict the impact of changes in the variables. Because the cases were written for different purposes, they lack a consistent framework, and it is difficult for the reader to distill the lessons for corporatization. Several of the reforms described are too new to judge their consequence or staying power. The cases provide little evidence that marketization works. Hopefully the issue will be better informed in the future by cases that address a prescribed framework of analysis. Without employing the term, Preker and Harding are moving toward a ‘‘requisite theory’’ of the total spectrum of public hospital reform processes. If it is to be useful, such a theory must move beyond economic modeling and accommodate all of the variables identified by case studies, placing them in categories, such as: alignment of the key variables; legal and constitutional situation; stability of public policy commitment; government infrastructure (financial management, civil service provisions, information systems); the managerial role and competencies; the place of market-like behaviors; and expectations (public, professional, political). The theory could be used to predict ‘‘tipping points’’ in the reform process. All of this may serve either to promote the introduction of autonomization, corporatization, or privatization—or to save public hospital systems from them.
TL;DR: Reasonable Rationing is a book about the intra-national experience of priority setting in health in five countries: Canada, The Netherlands, New Zealand, Norway, and the United Kingdom, and it provides substantial information about how these experiences have played out and how successful the efforts have been.
Abstract: Reasonable Rationing is, contrary to its title, a book about the intra-national experience of priority setting in health in five countries: Canada, The Netherlands, New Zealand, Norway, and the United Kingdom. It is certainly not an accident that the countries considered are all relatively rich countries with essentially universal coverage for health services. In a rich nation such as the United States, where a person is entitled to all the care he or she can afford, the question of priority setting rarely is addressed explicitly— with the exception, as the book notes, of Oregon. In the vast number of poor countries in the world, priority setting also is not addressed explicitly. Since there generally is neither revenue nor providers for such basic services as immunization or well baby care, deciding on the use of sophisticated and expensive procedures or technologies is just not on the radar screen. However, for those interested in the issues surrounding priority setting in wealthy countries with relatively universal access to medical care, this book provides five excellent case studies. What these case studies all confirm is that despite the efforts to develop ‘‘rational’’ priority setting mechanisms in all five countries, the actual decisions about available services are made at a variety of levels, by a variety of actors with motivations only rarely determined by costs and benefits. In short, priority setting in all these countries is a highly political process that involves much more than simply the rational consideration of whether a particular procedure will add more years to life than some other procedure that costs the same amount or less. The book is an easy read and, for the student of priority setting, it brings together the experience of the five countries in one volume. Having done so, it provides substantial information about how these experiences have played out and how successful the efforts have been. However, the book raises two considerably larger and different questions that are never explicitly stated, nor discussed. These are the importance of medical services per se, and the question of why rationing is important in the first place. In regard to the first issue—the importance of medical services—it is useful to note that in their discussion of Canada, Douglas Martin and Peter Singer point out that the Canadian health system has been rocked by a number of crises, including closings of facilities, reductions in lengths of stay due to lack of funds, longer waiting times for services, and declining reputation. They also say: ‘‘However, despite these ‘crises’ the health status of Canadians continues to improve—the infant mortality rate is 5.8 per 1,000 births, the life expectancy of Canadians is 79 years (second only to the Japanese)’’ (p. 44). Medical services are clearly important for some specific people in a valetudinarian state. But their importance for improving the health of populations is far outweighed by a number of other societal-level factors, such as the education of women, the gross national product, the availability of potable water, diet, television viewing, and travel by automobile. There have been few efforts to address the broader issues of priority setting in the expenditure of either public or private funds as this relates to the relative value of medical services compared to other reasonable interventions. Perhaps it is true that many medical interventions are available for use against specific disease, while few interventions exist, for example, to improve people’s diets. But perhaps this reflects the lack of attention that has been given to nutrition as a determinant of national health, or to the many other nonmedical determinants of national health. The second issue, it seems to me, is even more important. Why discuss rationing in the first place? The five countries considered are some of the richest in the world. Clearly, there is never enough money for everything that might be done. And these countries are not as rich individually, or even collectively, as a nation like the United States. Yet as exists in the United States, there is a vast reservoir of money in all of these countries. If priorities need to be set, it is not because the money for some particular medical procedure is not available, but because the decision has been made at some level not to spend the money on that procedure. The argument about the inability to pay for all care in the United States, in particular, seems to be based on a premise that a certain surgery or medical procedure will actually use up the available money—as if the dollars for the surgery’s cost will be taken behind the hospital and burned Inquiry/Volume 41, Spring 2004
TL;DR: Analysis of a change in "Medigap" regulations in Missouri in 1999 finds little evidence that the policy change affected premiums charged by insurance carriers in Missouri, but concludes that other desirable aspects of the change make it potentially attractive for other states to follow.
Abstract: This article analyzes a change in "Medigap" regulations that occurred in Missouri in 1999. It allows Medicare beneficiaries in the state to switch to a different carrier each year so long as they retain the same standardized policy type, without losing their open enrollment privileges. The analysis is based on a comparison of various outcomes in Missouri and those in two comparison states, Kansas and Florida. We found little evidence that the policy change affected premiums charged by insurance carriers in Missouri, but conclude that other desirable aspects of the change make it potentially attractive for other states to follow.