Showing papers in "Journal of Health Politics Policy and Law in 1987"

Small area analysis: a review and analysis of the North American literature.

Abstract: Variations in health service use rates by geographic area have long interested researchers and policymakers. Typically, investigators comparing population-based health care utilization rates among geographic areas have demonstrated substantial variations in use among seemingly similar communities. One method of investigation is "small area analysis." Numerous areas in North America have been studied extensively using this technique. This research has attempted to document the amount of variation found in health care use rates among areas; determine whether or not there is a pattern to such use in high- versus low-use areas; and identify the variables that are associated with the variation and explain a portion of the variation. Beyond this, many researchers have attempted to ascertain whether such variables are associated with characteristics of the population, whether they reflect differences in access and need, or whether a substantial portion of the variation is associated with differences in the medical care system itself. This review discusses the methods used to define the areas, the dependent variables that have been studied and the patterns found within them, the independent variables that have been tested, the statistical methods and analysis procedures used, the results of each study, and the policy recommendations emanating from the research. More importantly, based on what has been learned, the paper provides researchers in small area analysis with a set of recommendations for both analyzing and reporting results. These recommendations are designed to facilitate the development of a common research methodology, increase the comparability across studies, and enhance the use of this technique in the health policy formulation process.

Physicians' decisions to limit Medicaid participation: determinants and policy implications.

Abstract: Although most primary care physicians participate in state Medicaid programs, they may accept all Medicaid patients, or they may choose to limit their participation. This decision allows physicians to adjust their Medicaid caseloads to a desired level, and it has important implications for the access of low-income patients to health care. Surveys of pediatricians in 1978 and 1983 indicate that the proportion of pediatricians limiting their Medicaid participation increased significantly from 26 percent to 35 percent (p less than .001). In addition, in both 1978 and 1983, limited participants saw significantly fewer Medicaid patients than full participants. This paper describes a number of strategies available to federal and state policymakers for fostering full Medicaid participation. Multivariate analyses indicate that increasing reimbursement levels is an important strategy for encouraging full Medicaid participation. In addition, full participants will increase their Medicaid caseloads in response to a variety of Medicaid policy incentives, while limited participants are found to respond to fewer policy incentives. The authors conclude that caution will be needed to ensure that health care cost-containment strategies such as capitation or selective contracting do not inadvertently discourage participation among both full and limited Medicaid participants.

The new structure of individual practice associations.

Abstract: There are two types of HMOs: prepaid group practices (PGPs) and individual practice associations (IPAs). Because of rapid change in the HMO industry, the academic literature, which is based primarily on data from the 1970s, is dated in several ways. The literature has focused on PGPs, but IPAs are growing three times faster than PGPs and are likely to dominate the HMO industry in the near future. The literature indicates that a small proportion of an IPA physician's practice is capitated, but such practices often are as much as one-third capitated. And while the literature indicates that IPA physicians are rarely given financial incentives to control cost, such incentives are now common. In this decade IPAs have cut their hospital days per thousand enrollees. Furthermore, IPAs in which individual physicians or medical groups bear some of the financial risk of hospital costs appear to have the same rate of hospital days as PGPs. Additional research is especially needed on cost and quality of care in modern IPAs.

Nonprofit and for-Profit Medical Care: Shifting Roles and Implications for Health Policy

Abstract: The contemporary expansion of investor-owned health care facilities has stimulated much controversy but little response from policymakers. We believe this results from the apparently ambiguous relationship between ownership and socially valued outcomes. In our assessment, this ambiguity occurs largely because the effects of ownership are mediated in complex ways by characteristics of the services being delivered and the training of health care providers. Reviewing both the history and current performance of nonprofit and for-profit health care facilities, we identify some of the more important of these mediating factors. Taking these into account, there is a consistent influence of ownership on the delivery of health services. On the basis of this analysis, we discuss appropriate policy responses to the future growth of investor-owned health care organizations.

Defederalizing Medicaid: Fair to the Poor, Fair to Taxpayers?

Abstract: This paper explores the access and equity implications to the poor and taxpayers of further defederalizing Medicaid program administration. New data on enrollees and tax incidence indicates little horizontal, let alone vertical, equity in the system. Styles of cost control are also examined, showing a systematic bias towards providers and taxpayers at the expense of the poor in penurious states.

Improved access to care for the uninsured poor in large cities: do public hospitals make a difference?

Abstract: This study compares the volume of uncompensated care provided to the uninsured poor in cities with public hospitals to that provided in cities without a public hospital in order to determine whether public hospitals increase access to care. Multiple regression analysis is used to control for selected variables that also influence utilization of hospital care. Cities with public hospitals were found to provide between 31 and 34 uncompensated adjusted admissions per 100 uninsured poor; in cities without a public hospital, 24 such admissions were provided. In the regression analysis the coefficients for dummy variables representing three types of public hospital governance structures were all positive and statistically significant. The coefficient measuring teaching commitment among a city's hospitals was also positive and statistically significant. This analysis suggests that local tax support for public hospitals does not merely offset philanthropic or other revenue sources for voluntary hospital uncompensated care but is also likely to increase the amount of uncompensated care offered. We also find that public hospital closures may reduce access to care for the uninsured poor in large cities.

Selective contracting for hospital care based on volume, quality, and price: prospects, problems, and unanswered questions.

Abstract: There is a burgeoning interest in selective contracting for specialized hospital services based on volume, price, and quality. The systematic exclusion or inclusion of particular institutions has been extolled by some as an arrangement to reduce costs and by others as a means to increase quality of care. However, little is known about the issues and problems associated with selective contracting based on objective criteria rather than negotiations. Identification of individual institutions with performance significantly better or poorer than expected based on statistical norms is difficult and should be viewed as no more than a first step in evaluating quality and price performance. Actual data on 37 hospitals that provide coronary artery bypass graft surgery in a metropolitan region are used to illustrate some major prospects, problems, and situations arising when certain institutions are considered for exclusion from or inclusion in third-party payment programs. Selective contracting in local areas can potentially decrease duplication of services, reduce cost to purchasers, and lower expected mortality and morbidity for some patient groups. However, these gains must be evaluated against reductions in continuity of care and access to care, potential increases in mortality and morbidity for certain segments of the population, and substantial political problems.

Applying competitive bidding to health care.

Abstract: This paper reviews the empirical literature on competitive bidding for health services under public programs and, in this context, discusses the major issues that must be confronted in designing bidding systems. These issues include the specification of units of service, the selection of winning bidders, the determination of reimbursement for winning bidders, the treatment of losing bidders, and contract enforcement. The paper then illustrates these issues in practice by outlining one possible competitive bidding system for purchases and rentals of durable medical equipment under the Medicare program.

Confrontation, consent, and corporatism: state strategies and the medical profession in France, Great Britain, and West Germany.

Abstract: The economic disorders of the last decade have compelled European welfare states to seek more stringent controls over costly social policies such as health care, thus circumscribing professional sovereignty. However, several factors--institutional structure, cultural values, political/economic circumstances, patterns of state/professional relations--constrain the policy alternatives available to governments, and make fundamental reform very difficult to achieve. After analyzing these factors and the reform policies adopted in France, Great Britain, and West Germany, this article will examine and compare the strategies pursued to meet professional resistance to change.

Does all-payer rate setting work? The case of the New York Prospective Hospital Reimbursement Methodology.

Abstract: By 1983, four states had received waivers from the Health Care Financing Administration and adopted experimental reimbursement programs covering all third-party payers. In general, these programs were designed to moderate cost growth as well as to promote a number of broader distributive objectives. Among the concerns for equity were financing uncompensated care and spreading the costs across all payers, reducing the differential between hospital charges and costs, and rejuvenating fiscally distressed hospitals. These diverse goals represent a fundamental shift in the role of state rate setting; as a result, broader outcome measures are required to determine their overall impact. The New York Prospective Hospital Reimbursement Methodology (NYPHRM) is evaluated in this broader context. The NYPHRM successfully channeled revenues to fiscally blighted hospitals, increasing the volume of care to the uninsured while maintaining cost growth at national levels. According to this broader set of outcome measures, the NYPHRM would be viewed as a policy success.

The cohesion and fragmentation of organized medicine in France and the United States.

Abstract: The French and American medical professions share similar historical bases for strong political and economic market positions. As professions, the attributes of common education, ethics, and mission tend to keep physicians together in their political organization. But the medical professions in both France and the United States are also subject to intraprofessional forces of division, such as the conflicts which often oppose generalists to specialists. Although organized medicine in France and the United States shares these commonalities, there is a very important difference between the two countries. The French profession tends toward organizational particularism, both ideologically and nonideologically, which serves to splinter it in ways inimical to the interests of the medical profession. By contrast, the American medical profession tends to organize universally-that is, its organizational base is much more often one of unity and accommodation toward the divergent interests of physicians. Thus, organized medicine in the United States has more easily fought off political and economic pressures coming from government and the private sector-but by no means with total success. On the other hand, highly fragmented organized medicine in France has experienced an almost linear decline in the face of pressures coming from a determined and strong state.

Prospective payment based on case mix: will it work in nursing homes?

Abstract: This article evaluates the potential efficacy of implementing a prospective payment system based on case mix in the nursing home industry. The analysis of structural differences between the nursing home and hospital industries suggests that the mechanism of compensating long-term care facilities should be based on functional health status rather than on diagnosis and that incentives to improve quality and access should be strengthened. The article assesses several systems of classifying patients that have been proposed as the basis for implementing a prospective payment system in the nursing home industry. The article concludes with a discussion of policy issues related to the appropriate unit of payment and the scope of regulatory authority.

Hill-Burton: the unfulfilled promise.

Abstract: The poor and uninsured encounter numerous barriers to health care access. The Hill-Burton Act of 1946 required many hospitals to make their services available to all persons, yet ineffective enforcement has limited the utility of the act's requirements. Hill-Burton hospital audits have revealed widespread facility noncompliance. In light of these findings, alternative enforcement procedures should be considered.

An end to a consensus on health care in the Federal Republic of Germany

Abstract: Over the past fifteen years the national government in the Federal Republic of Germany has animated the political debate about rising health care expenditures. However, it has only provided health policy leadership by shifting the burden of financing health and medical care to others. This paper presents three cases that illustrate the political and institutional constraints inherent in the German policy process that limit the proposal and implementation of appropriate policy solutions to rising health care costs. Cost controls have been inhibited because of the near-universal entitlement of national health insurance, the access all social groups have to advanced medical care, and policies targeted at providers rather than users of health services. The paper also underscores the past and future importance of regional policy coalitions in shaping national health policy.

HMO promotion and the privatization of health care in Chile.

Abstract: Since 1973 the Chilean junta has privatized sectors of the national economy. This paper analyzes the country's policy process of promoting private medical programs through HMO-like plans (ISAPREs, or Institutes of Provisional Health). These plans have captured less than half of their originally anticipated market share. It is argued that the future performance of ISAPREs will be undermined by their limited maternal benefits, their targeting to a small upper-income group which cannot sustain many private medical programs, and competition with less expensive yet equally competent public medical programs. The paper briefly compares privatization in Chile with the experiences of other countries, and specifically contrasts the restructuring of health services under military rule in Chile with those of Argentina and Uruguay. The paper concludes that the Chilean experience with HMOs epitomizes the perils of planning health care during short-term periods of economic prosperity as well as failing to consult medical care providers and consumers.

Health Care Financing Among the Elderly: Who Really Pays the Bills?

Abstract: This paper investigates the issue of who pays the health care bills of the elderly by considering the types of subsidized health insurance protection enjoyed by the noninstitutionalized elderly and the way that increased Medicare cost-sharing efforts in the 1980s are affecting those without additional health insurance subsidies In making this examination we estimate the out-of-pocket health care expenditures of the elderly either directly or as nonsubsidized medigap premiums by income level, taking into account four types of health insurance subsidies received by elderly persons: Medicare, Medicaid, Veterans Administration health care, and subsidized health insurance from either current or former employers We find that increased cost sharing is likely to fall most heavily on those elderly least likely to afford it: the poor and near-poor elderly who have only Medicare as a health insurance subsidy, particularly those who are older and sicker and who use Medicare services more heavily These persons are caught between well-intentioned federal cost-cutting efforts and the often confusing panoply of health insurance programs for the aged, and they will bear an inequitably large portion of any future Medicare cost-sharing initiatives

Suicide and civil commitment

Abstract: The contemporary approach to suicide prevention relies primarily on involuntary commitment of the suicidal individual. While there is generally widespread acceptance of the principle of society's right, even its moral obligation, to intervene to prevent a suicide, there is much less agreement concerning the conditions under which such an action should proceed. Most of the debate centers on the widely applied commitment criteria of mental illness and dangerousness to self and others. Questions have also been raised regarding the efficacy of commitment as a preventive measure. In this paper, these controversies are placed in a broader historical context. We examine empirical evidence concerning prevailing commitment criteria and the prophylactic value of involuntary hospitalization, and discuss the appropriateness of our current approach to civil commitment in light of existing data.

Worker responses to workplace hazards.

Abstract: Recent policy initiatives in occupational safety and health have emphasized strategies that provide workers with information about workplace exposures. It is not clear, however, what effect this new information has had or will have on worker self-help initiatives. This paper analyzes individual and collective worker responses to information on job hazards using five sources of data on workers and industries in the United States. Levels of expressed dissatisfaction, discharges for cause, and strike frequencies are found to be significantly higher in hazardous jobs than in safe jobs. Individual quit strategies are not consistently found to be associated with higher hazard levels. These findings have potentially important implications for the design of future information-oriented health and safety policies.

The effect of state regulations on the quality and sale of insurance policies to Medicare beneficiaries.

Abstract: This paper examines the effects of state regulations on the quality of insurance policies sold to Medicare beneficiaries and on the amount of sales abuse reported in the sale of such policies. State regulations regarding such policies relate to policy content and format, minimum rates of return, sale of these policies related to disclosure requirements, consumer information activities, and penalties for agent and company abuse. This paper examines the impact of specific regulations on the ratio of the expected policy benefits per premium dollars and on the number and kind of abusive sales practices reported by purchasers and nonpurchasers in agent and mail sales. The study finds that loss ratio floors, minimum benefit standards, and the development of states of consumer information guides for prospective policyholders have a positive impact on the quality of the policies purchased. In addition, the study finds that the amount of abuse reported is less when insurance companies routinely issue press releases concerning agent or company misrepresentation and when consumer guides are developed and available from the state.

Using home equity to finance long-term care.

Abstract: A majority of elderly Americans have the bulk of their assets tied up in the houses they own. Reverse mortgages could tap this home equity, providing loan disbursements without requiring older homeowners to make monthly payments on principal and interest. In this paper we analyze the potential of using home equity to finance long-term care of the elderly, including payments for home care and for long-term care insurance. We first estimate each homeowner's risk of need for care (and risk of institutionalization) and then calculate the degree to which home equity could be used to cover the costs of home care (or of insurance premiums). Special emphasis is placed on those in the highest risk group and on those with the lowest incomes, who often turn out to be the same people.

Implementing change: lessons for Medicaid reformers.

Abstract: Major Medicaid reforms initiated in Arizona, California, and New York in the 1980s form the foundation of this study, which explores issues to consider when implementing change in state Medicaid programs We prepared case studies of these reforms, describing the innovations and assessing the implementation process in each state These case studies are used to illustrate broad issues and processes of Medicaid reform Six lessons emerge from our analysis: Expect reform models to change over time; strive for predictability and continuity in the reform; encourage behavior changes through the use of incentives; use special administrative or political channels to simplify the reform; expect reform models to converge over time; and implementation difficulties can be predicted These lessons should educate decision makers about how to implement possible future solutions to problems like those seen in Medicaid programs at the start of this decade

The Complexities of Managed Care: Operating a Voluntary System

Abstract: The implementation of state-sponsored voluntary case management programs for public assistance recipients creates provider and recipient recruiting problems that are unique to the state's economic environment, its political climate, its historic relationship with providers, its program goals, and its implementation strategies. This implementation study discusses the factors that influenced the operationalization of the Massachusetts managed care program for AFDC families. The issues of provider recruitment and recipient enrollment are examined in relation to the formal program goals of cost containment and access. The operational and bureaucratic problems the state Medicaid staff has experienced in maintaining the program evokes questions of who should administer the programs, who the best types of providers are in light of program goals, and how recipients can be enrolled in a voluntary program.

Psychosurgery and the Abuse of Psychiatric Authority in Ontario

Abstract: Over the past two decades political and legal decisions have sharply curtailed psychiatric authority. One area in which psychiatric authority has been most limited is psychosurgery. This paper uses archival evidence from Ontario to show how psychiatrists ordered and administered psychosurgery for a wide variety of reasons. In some cases psychosurgery was administered to ease staffing problems, for experimental purposes, or simply out of sheer curiosity. Often the consent of patients or relatives was not obtained. This egregious abuse of psychiatric authority contributed to the critical movement against psychiatry and to strict laws limiting and sometimes banning resort to psychosurgery.

The Political Development of the Hill-Burton Program: A Case Study in Distributive Policy

Abstract: The Hill-Burton program offers a rare opportunity to study a distributive health policy from its adoption to its elimination. This study reveals that the political dynamics of the policy changed over time. It concludes by observing that interest group influence on distributive health policies may only be decisive when circumstances permit. Those circumstances include the involvement of powerful elected officials and the degree of consensus among policy experts about the need for the policy and the appropriateness of its objectives.