bluuebunny/crossref_metadata_2025 huggingface dataset:
Health and the Cost of Nongroup Insurance
Authors: Hadley Jack , Reschovsky James D.
Published: August 2011

This analysis estimates a selection-adjusted model of the premium for nongroup insurance to measure the effect of health status on the cost of nongroup insurance. Using data from two recent national surveys, the probability of buying nongroup insurance is about 50% lower for people in fair or poor health compared to similar people in excellent health. Correcting for selection, premiums are about 15% higher for people with modest health problems, and 43% to 50% higher for people with major health problems compared to those in excellent health. We use the selection-corrected premiums to simulate the effects on the price and affordability of nongroup insurance for the uninsured under two recent tax credit proposals.
Improving Nurse Staffing Measures: Discharge Day Measurement in “Adjusted Patient Days of Care”
Authors: Unruh Lynn Y. , Fottler Myron D. , Talbott Laura L.
Published: August 2011

Previous research cannot account for the discrepancy between registered nurse (RN) reports of understaffing and studies showing slight improvement. One reason may be that “adjusted patient days of care”(APDC) underestimates patient load. Using data from all Pennsylvania acute care general hospitals for the years 1994 through 1997, we found that APDC is underestimated by two hours. After adjusting APDC, we examined the difference in nurse staffing over the period 1991–2000 before and after the adjustment. We found a significant difference between unadjusted and adjusted measures. However, when applied to the changes in nurse staffing between 1991 and 2000, the difference was not enough to account for the discrepancy between reports and data. Other measurement and conceptual problems may exist in terms of patients' increasing acuity levels, patients' declining lengths of stay and the associated greater proportion of nurse time devoted to admission and discharge, and lack of recent data in some empirical studies.
Letters to the Editor
Authors: Rosko Michael D.
Published: August 2011

As part of marking Inquiry's 40th year of publication, we are introducing a new feature to the journal—a “Letters to the Editor” section. We invite interested readers to send their comments on research articles or opinion columns published in the journal. Letter topics may range from critiques of methods or models used in articles to presenting alternative views on subjects raised in opinion columns or in interpretations of research findings. Letters should be no longer than 750 words; Inquiry's editors reserve the right to edit the letters for clarity and length. Letters selected for publication will undergo our usual copyediting process; we cannot acknowledge receipt of letters that are not published. Submit letters to: Letters to the Editor, Inquiry, P.O. Box 25399, Rochester, NY 14625–0399.
Nonprofit Health Insurers: The Story Wall Street Doesn't Tell
Authors: Johnson Susan R.
Published: August 2011

For several years, Wall Street investment firms have campaigned for conversion of nonprofit health insurers to investor ownership, arguing that an infusion of equity capital is critical to insurers' survival. However, closer examination of the financial performance and capital position of not-for-profit health plans shows that:

□ The lower operating margins reported by not-for-profit health plans very likely reflect the organizations' corporate missions to serve their communities by minimizing the cost of coverage and their ability to invest all gains back into the company for the future benefit of their customers. Their investor-owned counterparts must generate higher margins to give shareholders a return on their investment. □ Compared with investor-owned insurers, not-for-profit health plans use a significantly higher percentage of the customers' premium dollar to pay health care claims. A lower percentage goes for administrative expenses. □ Over the past 10 years, not-for-profit health plans have succeeded in using operational and investment gains to build and retain a strong capital position—stronger than that of investor-owned companies—while investing heavily in infrastructure, product development, and market growth.
Does Quality Influence Consumer Choice of Nursing Homes? Evidence from Nursing Home to Nursing Home Transfers
Authors: Hirth Richard A. , Banaszak-Holl Jane C. , Fries Brant E. , Turenne Marc N.
Published: August 2011

We estimated Cox proportional hazards models using assessment data from the Minimum Data Set to test whether nursing home residents and their proxies respond to quality of care by changing providers. Various indicators of poor quality increased the likelihood of transfer. Residents of for-profit homes or homes with excess capacity also were more likely to transfer. Inability to participate in care decisions and factors indicating frailty limited residents' ability to transfer. The apparent responsiveness to quality is encouraging. Nonetheless, because the absolute transfer rate is low, significant barriers to movement among nursing homes still may exist.
Medicaid Community-Based Programs: A Longitudinal Analysis of State Variation in Expenditures and Utilization
Authors: Kitchener Martin , Carrillo Helen , Harrington Charlene
Published: August 2011

As states face challenges posed by budget crises and pressures to develop Medicaid home and community-based services (HCBS), this paper provides a longitudinal analysis of state variation in expenditures and utilization for three HCBS programs (waivers, home health and personal care), and for total Medicaid HCBS. The first part of the analysis describes the nature and scope of state variation for each program in 1999, using such measures as participants per 1,000 population and expenditures per capita. The second part of the analysis presents time-series regression models that estimate sociodemographic, state policy, and market factors associated with intra-state variation in waiver participants and expenditures, and home health, personal care and total HCBS expenditures for the period 1992–99. Among the results, positive state-level factors related to HCBS participants and expenditures include: higher percentages of aged people, greater incomes per capita, and a larger supply of home health agencies.
The Impact of Local Welfare Offices on Children's Enrollment in Medicaid and SCHIP
Authors: Allison R. Andrew
Published: August 2011

Nearly 20% of children entering Kansas' State Children's Health Insurance Program (SCHIP) and more than 25% of children entering the state's Medicaid program leave public health insurance altogether before completing a full year of coverage, when the first redetermination of eligibility should occur. Analyses of administrative data indicate that high rates of premature disenrollment are strongly associated with case management practices at local social services offices. However, local offices enroll the vast majority of children into public health insurance. To avoid a potential trade-off between local offices' impact on enrollment and retention, the study suggests that states such as Kansas consider improvements in automation to support caseworkers' difficult jobs.
A Framework for Evaluating Safety-Net and other Community-Level Factors on Access for Low-Income Populations
Authors: Davidson Pamela L. , Andersen Ronald M. , Wyn Roberta , Brown E. Richard
Published: August 2011

The framework presented in this article extends the Andersen behavioral model of health services utilization research to examine the effects of contextual determinants of access. A conceptual framework is suggested for selecting and constructing contextual (or community-level) variables representing the social, economic, structural, and public policy environment that influence low-income people's use of medical care. Contextual variables capture the characteristics of the population that disproportionately relies on the health care safety net, the public policy support for low-income and safety-net populations, and the structure of the health care market and safety-net services within that market. Until recently, the literature in this area has been largely qualitative and descriptive and few multivariate studies comprehensively investigated the contextual determinants of access. The comprehensive and systematic approach suggested by the framework will enable researchers to strengthen the external validity of results by accounting for the influence of a consistent set of contextual factors across locations and populations. A subsequent article in this issue of Inquiry applies the framework to examine access to ambulatory care for low-income adults, both insured and uninsured.
Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities
Authors: Brown E. Richard , Davidson Pamela L. , Yu Hongjian , Wyn Roberta , Andersen Ronald M. , Becerra Lida , Razack Natasha
Published: August 2011

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. Drawing on a conceptual behavioral and structural framework of access, the authors developed multivariate models for insured and uninsured lower-income adults to assess the adjusted effects of community- and individual-level factors on two indicators of access: having a usual source of care, and having at least one physician visit in the past year. Several community factors influenced access, but they did so differently for insured and uninsured adults and for the two measures of access used. 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, such as Medicaid payments and safety-net clinics, can lead to measurable improvements in access for vulnerable populations residing in large urban areas.
The Sea Change in Nonprofit Governance: A New Universe of Opportunities and Responsibilities
Authors: Connelly Michael D.
Published: August 2011

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.
Increased Medicare Expenditures for Physicians' Services: What are the Causes?
Authors: Buntin Melinda J. Beeuwkes , Escarcé Jose J. , Goldman Dana , Kan Hongjun , Laugesen Miriam J. , Shekelle Paul
Published: August 2011

In light of rising expenditures for physicians' services and the scheduled decreases in the amounts Medicare pays for such services, we identified the sources of change in the volume and intensity of Medicare physicians' services. We found that the per capita volume and intensity of physicians' services used by Medicare beneficiaries increased more than 30% between 1993 and 1998. Our analyses indicated that, at most, half of this increase was due to measurable changes in the demographic composition, places of residence, prevalence of health conditions, and managed care enrollment of beneficiaries. The other half was due to a general increase in the use of care across beneficiary categories.
Smoke without Fire: Nursing Facility Closures in California, 1997–2001
Authors: Kitchener Martin , Bostrom Alan , Harrington Charlene
Published: August 2011

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%.
Assessing Risk-Adjustment Approaches under Non-Random Selection
Authors: Luft Harold S. , Dudley R. Adams
Published: August 2011

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.
Comparing Accuracy of Risk-Adjustment Methodologies Used in Economic Profiling of Physicians
Authors: Thomas J. William , Grazier Kyle L. , Ward Kathleen
Published: August 2011

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.
Doing Away with Uncompensated Care of the Uninsured
Authors: Sigmond Robert M.
Published: August 2011

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 inpatient care to more productive, innovative community initiatives. 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. The program can be carried out by an individual provider organization, or as a collaborative program involving two or more organizations. Recommended are demonstration projects to test the feasibility and net cost or cost savings of such an approach, preferably starting in one-hospital towns.
The Managed Care Backlash: Did Consumers Vote with Their Feet?
Authors: Marquis M. Susan , Rogowski Jeannette A. , Escarce José J.
Published: August 2011

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.
State Payment Limitations on Medicare Cost-Sharing: Impact on Dually Eligible Beneficiaries
Authors: Mitchell Janet B. , Haber Susan G.
Published: August 2011

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.
The Effect of Medicare's Prospective Payment System on Discharge Outcomes of Skilled Nursing Facility Residents
Authors: Wodchis Walter P. , Fries Brant E. , Hirth Richard A.
Published: August 2011

In July 1998, the Centers for Medicare and Medicaid Services (CMS) changed the payment method for Medicare (Part A) skilled nursing facility (SNF) care from a cost-based system to a prospective payment system (PPS). Unlike the previous cost-based payment system, PPS restricts skilled nursing facility payment to pre-determined levels. CMS also reduced the total payments to SNFs coincident with PPS implementation. These changes might reduce quality of care at skilled nursing facilities and could be reflected in resident discharge patterns. The present study examines the effect of the 1998 policy change on resident discharge outcomes. The results indicate that PPS reduced the relative risk of discharge to home and to death for Medicare residents (compared to non-Medicare residents) and had no significant effect on hospitalizations or transfers.
Does Improving Geographic Access to VA Primary Care Services Impact Patients' Patterns of Utilization and Costs?
Authors: Fortney John C. , Maciejewski Matthew L. , Warren James J. , Burgess James F.
Published: August 2011

The Department of Veterans Affairs (VA) has been establishing community-based outpatient clinics (CBOCs) across the country to improve veterans' access to and use of primary care services, thereby decreasing the need for costly specialty outpatient and inpatient care. Using a quasi-experimental, pre-post study design, we examined whether the establishment of CBOCs has affected access, use, and costs for VA patients residing in their catchment areas. Most patients residing in CBOC catchment areas did not receive care at CBOCs, resulting in only small increases in primary care utilization. While CBOCs improved veterans' access, they had little impact on overall patterns of utilization and cost.
Hospital Finances and Patient Safety Outcomes
Authors: Encinosa William E. , Bernard Didem M.
Published: August 2011

Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.
Has Competition Lowered Hospital Prices?
Authors: Zwanziger Jack , Mooney Cathleen
Published: August 2011

On Jan. 1, 1997, New York ended its regulation of hospital prices with the intent of using competitive markets to control prices and increase efficiency. This paper uses data that come from annual reports filed by all health maintenance organizations (HMOs) operating in New York and include payments to and usage in the major hospitals in an HMO's network. We estimate the relationship between implied prices and hospital, plan, and market characteristics. The models show that after 1997, hospitals in more competitive markets paid less. Partially offsetting these price reductions were price increases associated with hospital mergers that reduced the competitiveness of the local market. Hospital deregulation was successful, at least in the short run, in using price competition to reduce hospital payments; it is unclear whether this success will be undermined by the structural changes taking place in the hospital industry.
Spillover Effects of Benefit Expansions and Carve-Outs on Psychotropic Medication Use and Costs
Authors: Zuvekas Samuel H. , Rupp Agnes E. , Norquist Grayson S.
Published: August 2011

This paper extends the previous literature examining the impacts of managed behavioral health care carve-outs and mental health parity mandates on mental health and substance abuse (MH/SA) specialty treatment use and costs by considering the effects on psychotropic prescription medication costs. We use multivariate panel data methods to remove underlying secular growth trends, driven by increased demand for improved MH/SA treatment related to pharmaceutical innovations. We find that psychotropic medication costs continued to increase after the introduction of a substantial benefit expansion and carve-out to a managed behavioral health organization (MBHO), offsetting large declines in inpatient specialty MH/SA costs. However, we find evidence that the MBHO may have restrained growth in prescription medication spending.
Welfare Reform, Insurance Coverage Pre-Pregnancy, and Timely Enrollment: An Eight-State Study
Authors: Adams E. Kathleen , Gavin Norma I. , Manning Willard G. , Handler Arden
Published: August 2011

Implementation of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) broke the automatic linkage between Medicaid eligibility/enrollment and welfare cash assistance for women eligible at welfare income levels. This study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for the period 1996–1999 to examine insurance coverage of these and other pregnant women pre- and post-PRWORA. Controlling for individual characteristics and economic growth, the relative odds of having private insurance did not change while the odds of being Medicaid enrolled versus uninsured pre-pregnancy declined for welfare-eligible women post-PRWORA. The absolute effect was a decline of 7.9 percentage points in the probability of welfare-eligible women being insured. While these results apply to the early years of welfare reform, it is still likely that states can improve Medicaid outreach and enrollment of women eligible prior to pregnancy.
Plan Choice and Changes in Access to Care over Time for SSI-Eligible Children with Disabilities
Authors: Roberto Pamela N. , Mitchell Jean M. , Gaskin Darrell J.
Published: August 2011

This paper analyzes how voluntary enrollment in the fee-for-service (FFS) system versus a partially capitated managed care plan affects changes in access to care over time for special needs children who receive Supplemental Security Income (SSI) due to a disability. Four indicators of access are evaluated, including specialty care, hospital care, emergency care, and access to a regular doctor. We employ the Heckman two-step estimation procedure to correct for the potential nonrandom selection bias linked to plan choice. The findings show that relative to their counterparts in the partially capitated managed care plan, SSI children enrolled in the FFS plan are significantly more likely to encounter an access problem during either of the time periods studied. Similarly, FFS enrollees are significantly more likely than partially capitated managed care participants to experience persistent access problems across three of the four dimensions of care. Possible explanations for the deterioration in access associated with FFS include the lack of case management services, lower reimbursement relative to the partially capitated managed care plan, and provider availability.
Transforming the Accreditation of Health Care Management Education
Authors: Dalston Jeptha W. , Prybil Lawrence D. , Berman Howard , Lloyd John S.
Published: August 2011

Recognizing the considerable changes occurring over recent years in health care, the Accrediting Commission on Education for Health Services Administration (ACEHSA) sought to remake itself to become a more vital participant in the field. This article reports the rationale, objectives, and process pursued by ACEHSA as it underwent this transformation and adopted a new name: Commission on Accreditation of Healthcare Management Education (CAHME). This paper features the planning document adopted to lead CAHME through the future. It also highlights actions taken to date and subsequent steps planned.
Long-Term Care over an Uncertain Future: What Can Current Retirees Expect?
Authors: Kemper Peter , Komisar Harriet L. , Alecxih Lisa
Published: August 2011

The leading edge of the baby boom generation is nearing retirement and facing uncertainty about its need for long-term care (LTC). Using a microsimulation model, this analysis projected that people currently turning age 65 will need LTC for three years on average. An important share of needed care will be covered by public programs and some private insurance, but much of the care will be an uninsured private responsibility of individuals and their families—a responsibility that will be distributed unequally. While over a third of those now turning 65 are projected to never receive family care, three out of 10 will rely on family care for more than two years. Similarly, half of people turning 65 will have no private out-of-pocket expenditures for LTC, while more than one in 20 are projected to spend $100,000 or more of their own money (in present discounted value). Policy debate that focuses only on income security and acute care—and the corresponding Social Security and Medicare programs—misses the third, largely private, risk that retirees face: that of needing LTC.
Medicare's Prospective Payment System for Skilled Nursing Facilities: Effects on Staffing and Quality of Care
Authors: White Chapin
Published: August 2011

In 1998, Medicare began phasing in a new prospective payment system (PPS) for skilled nursing facilities (SNFs). This paper measures facility-level changes in nurse staffing and quality at freestanding SNFs from 1997 (pre-PPS) to 2001 (post-PPS). Findings show a positive but small association between changes in payment levels and changes in nurse staffing. Among for-profits, the elimination of cost reimbursement is associated with a large drop in nurse staffing. Additionally, the elimination of cost reimbursement is associated with worsening in one of four measures of quality of care; however, the quality results are not statistically robust.
Health Insurance Reform and HMO Penetration in the Small Group Market
Authors: Buchmueller Thomas C. , Liu Su
Published: August 2011

This study uses data from several national employer surveys conducted between the late 1980s and the mid-1990s to investigate the effect of state-level underwriting reforms on HMO penetration in the small group health insurance market. We identify reform effects by exploiting cross-state variation in the timing and content of reform legislation and by using mid-sized and large employers, which were not affected by the legislation, as within-state control groups. While it is difficult to disentangle the effect of state reforms from other factors affecting HMO penetration in the small group markets, the results suggest a positive relationship between insurance market regulations and HMO penetration.
Price and the Demand for Nongroup Health Insurance
Authors: Auerbach David , Ohri Sabina
Published: August 2011

In light of recent interest in tax credits and other price-based incentives to stimulate the purchase of insurance, this study estimates the price elasticity of demand for nongroup health insurance for single workers without access to employer-sponsored insurance. Our premium measure explicitly accounts for two components that have not been examined in previous studies: 1) health status, and 2) the effect of state-level premium rating regulations. We estimate a price elasticity of –.59, which, given the low rate of initial coverage in our sample (16.4%), translates to a small effect on the uninsured.
Access to Health Care after Welfare Reform
Authors: Seccombe Karen , Newsom Jason , Hoffman Kim
Published: August 2011

This research uses data from a longitudinal statewide study of Oregon families leaving Temporary Assistance to Needy Families (TANF) to identify: 1) the trends in insurance coverage over time; 2) the role of health insurance coverage in predicting whether respondents received needed medical care; and 3) the relationship between access to care and physical and mental health. Data were obtained from 637 families seven months after leaving welfare for work; 552 of these families were re-interviewed one year later. The data reveal that 40% of TANF leavers were uninsured at wave 2 and suggest that significant access barriers exist, which may be associated with poor health outcomes.
Survival Skills for the Political Environment of Health Insurance
Authors: Weissert William G.
Published: August 2011

Blue Cross Blue Shield of Michigan asked the Michigan state government for small group market rate reform already adopted in most other states. Officials responded with major restructuring proposals aimed specifically at the Blues. The Michigan Blues fought back with a massive lobbying campaign as vigorous as any mounted by opponents of health reform at the national level. The company was able to prevail over one of the most powerful governors in Michigan history, whose party controlled both houses of the legislature. This amazing political victory shared much in common with the Clinton health reform's defeat by the industry and the more recent success of the prescription drug industry in shaping Medicare prescription drug reform to its liking. The experience suggests that political savvy and lobbying skills have become core competencies in the health care industry.
How Do Households Choose Their Employer-Based Health Insurance?
Authors: Abraham Jean Marie , Vogt William B. , Gaynor Martin S.
Published: August 2011

Using the 1996 Medical Expenditure Panel Survey, this study estimates a model of household demand for employer-based health insurance to investigate the set of plan and household characteristics that influence coverage choices. Overall, we find that households are sensitive to price with respect to their coverage decisions, and that price sensitivity varies by marital status, wealth, and the number of offers of employer coverage available to the household. We also find that lower-income households are less likely to select an option that provides coverage for all household members. Using our model estimates, we simulate the effect of employers offering various levels of “opt-out” payments on changes in workers' probabilities of not taking up coverage and on expected costs.
Money and Mandates: Relative Effects of Key Policy Levers in Expanding Health Insurance Coverage to All Americans
Authors: Lambrew Jeanne M. , Gruber Jonathan
Published: August 2011

This study examines the relative effects of three policy levers on health coverage and costs in plans aimed at covering all Americans. Specifically, using microsimulation analysis and hypothetical proposals, it assesses how the generosity of financial assistance, an employer mandate, and an individual mandate affect the level of uninsurance, distribution of coverage, and federal costs, holding delivery system and benefits constant. The results suggest that only an individual mandate would cover all the uninsured; neither an employer mandate nor generous subsidies alone would be sufficient. The distribution of coverage would be least disrupted by an employer mandate, while 7.3% of people could lose employer coverage with generous subsidies and a voluntary purchasing pool. Federal costs would be highest under a combined individual and employer mandate since there would be costs to minimize disruption. Although less generous subsidies coupled with an individual mandate could yield universal coverage at a low federal cost, doing so would require large, new payments by individuals. Other key trade-offs are discussed.
Effects of Premium Increases on Enrollment in SCHIP: Findings from Three States
Authors: Kenney Genevieve , Allison R. Andrew , Costich Julia F. , Marton James , McFeeters Joshua
Published: August 2011

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire—three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004–2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.
Length of Hospice Care among U.S. Adults: 1992–2000
Authors: Han Beth , Remsburg Robin E. , McAuley William J. , Keay Timothy J. , Travis Shirley S.
Published: August 2011

This study examined length of service use among U.S. adult hospice patients based on data from the 1992–2000 National Home and Hospice Care Surveys. With the Kaplan-Meier method, we estimated length of service use of current and discharged hospice patients simultaneously. Using a multivariate Cox proportional hazards model, we examined trends in patients' service use during the 1990s. Findings show that length of service use decreased significantly among adult patients who had Medicare as their only payment source. Although overall length of service use declined significantly in 1996, 1998, and 2000 compared to 1992, it was similar between 1996 and 2000.
Consumer-Directed Health Plans: New Evidence on Spending and Utilization
Authors: Feldman Roger , Parente Stephen T. , Christianson Jon B.
Published: August 2011

This study examined three-year spending and utilization trends associated with enrollment in a consumer-directed health plan (CDHP) offered by a large employer alongside a preferred provider organization (PPO) and a point-of-service (POS) plan. The CDHP cohort spent considerably more money on hospital care than the POS cohort. Results found evidence of pent-up demand in the CDHP, but not enough to explain the spending trend. Lower prescription drug spending—where the CDHP modestly controlled allowable costs—was associated with less hospital and emergency room use in following periods. Findings suggest the CDHP had too little out-of-pocket cost-sharing to control medical spending.
Nursing Home Use by Dual-Eligible Beneficiaries in the Last Year of Life
Authors: Liu Korbin , Wissoker Douglas , Swett Althea
Published: August 2011

Research on health care at the end of life has focused on Medicare-financed acute care services. Much less information has been available on nursing home use in the last year of life, particularly for individuals who are dually eligible for Medicare and Medicaid. We used Medicare and Medicaid enrollment and claims data to examine nursing home admissions, odds of dying in nursing homes versus hospitals or the community, and variations in Medicare and Medicaid service use and costs by place of death. We found that, in the last year of life, 75% of dual-eligible people use nursing home care, increasing age is associated with greater likelihood of dying in nursing homes, and dual-eligible people who die in hospitals have notably higher costs than other beneficiaries.
Will Part D Produce Savings in Part A and Part B? The Impact of Prescription Drug Coverage on Medicare Program Expenditures
Authors: Stuart Bruce C. , Briesacher Becky A. , Doshi Jalpa A. , Wrobel Marian V. , Baysac Fatima
Published: August 2011

This paper addresses the question of whether prescription drug coverage for Medicare beneficiaries is associated with lower spending for hospital and physician services. We discuss the theoretical rationale for this relationship and the empirical challenges in estimating it. We then test the hypothesis using data from the 1999 and 2000 Medicare Current Beneficiary Surveys. Our results suggest that while drug coverage significantly increases spending on medications, there is no consistent evidence of increases or decreases in Medicare spending for hospital or physician services. We conclude that the cost of the new Medicare Part D drug benefit is unlikely to produce cost offsets elsewhere in the program.
Paying Their Way? Do Nonprofit Hospitals Justify Their Favorable Tax Treatment?
Authors: Schneider Helen
Published: August 2011

This study addresses the effect of hospital ownership on the delivery of services to medically indigent patients and on their communities, using two alternative definitions of community benefits. Using data from hospitals in California, the study finds that in similar markets, the amount of community benefits provided by a tax-exempt private hospital is equivalent in value to that provided by an investor-owned hospital. These results are sensitive to the definition of community benefits, thus indicating need for a more explicit identification and minimum standard of the community benefits expected of nonprofit hospitals in return for their special tax treatment.
Estimating Regression Standard Errors with Data from the Current Population Survey's Public Use File
Authors: Davern Michael , Jones Arthur , Lepkowski James , Davidson Gestur , Blewett Lynn A.
Published: August 2011

This study examines whether reasonable standard errors for multivariate models can be calculated using the public use file of the Current Population Survey's Annual Social and Economic Supplement (CPS ASEC). We restrict our analysis to the 2003 CPS ASEC and model three dependent variables at the individual level: income, poverty, and health insurance coverage. We compare standard error estimates performed on the CPS ASEC public use file with those obtained from the Census Bureau's restricted internal data that include all the relevant sampling information needed to compute standard errors adjusted for the complex survey sample design. Our analysis shows that the multivariate standard error estimates derived from the public use CPS ASEC following our specification perform relatively well compared to the estimates derived from the internal Census Bureau file. However, it is essential that users of CPS ASEC data do not simply choose any available method since three of the methods commonly used for adjusting for the complex sample design produce substantially different estimates.
How Much is Enough? An Evidence-Based Framework for Setting Medicaid Payment Rates
Authors: Quinn Kevin
Published: August 2011

This article proposes an evidence-based framework for Medicaid programs to use in setting payment levels for any health care service. The purpose of payment is seen from the beneficiary's perspective, that is, enabling access to quality services. The approach is to measure access as directly as possible, to make findings about payment adequacy, and to take action in a way that maximizes the return (i.e., access to quality care) on Medicaid's investment. This approach differs from both the theoretical ideal and from much of the past practice in Medicaid rate setting. The paper offers examples of evidence, findings, and actions.
Why Do Hispanics Have So Little Employer-Sponsored Health Insurance?
Authors: Reschovsky James D. , Hadley Jack , Nichols Len
Published: August 2011

This paper investigates low rates of employer health insurance coverage among Hispanics using national data from the Community Tracking Study Household Survey. Interview language served as a proxy for the degree of assimilation. Findings indicate that English-speaking Hispanics are more similar to whites in their labor market experiences and coverage than they are to Spanish-speaking Hispanics. Spanish-speakers' very low human capital (including their inability to speak English) results in much less access to job-based insurance. Though less important, Spanish-speaking Hispanics' demand for employer-sponsored insurance appears lower than that of English-speaking Hispanics or whites. Results suggest that language and job training may be the most effective way to bolster Hispanics' insurance coverage.
The Relative Importance of Worker, Firm, and Market Characteristics for Racial/Ethnic Disparities in Employer-Sponsored Health Insurance
Authors: Haas Jennifer , Swartz Katherine
Published: August 2011

The characteristics of an individual, the local labor market, and the firm where an individual is employed each may be associated with racial and ethnic disparities in employer-sponsored insurance (ESI). This study estimates two models to determine the relative effects of each of these three sets of characteristics on the likelihood a worker has a job with ESI. One model has two outcomes: the job comes with ESI or not. The other model has five possible outcomes: the individual is not offered ESI and is uninsured; the individual is not offered ESI and is insured; the individual is offered ESI but turns it down and is uninsured; the individual is offered ESI but turns it down and is insured; and the individual is offered ESI and accepts. Findings indicate that individual characteristics and firm characteristics are more likely to have significant and substantial effects on the probability that a person has ESI, while the effects of market characteristics appear to be conveyed through firm characteristics. Being African American or Hispanic is not significantly associated with having ESI in the two-outcomes model, but in the five-outcomes model each is associated significantly with being uninsured, either because the person has not been offered ESI or has declined offered coverage. Clearly, examining more nuanced outcomes is more informative about the role of race and ethnicity in why working people are uninsured.
Individual Health Insurance within the Family: Can Subsidies Promote Family Coverage?
Authors: Kapur Kanika , Escarce José J. , Marquis M. Susan
Published: August 2011

This paper examines the role of price in health insurance coverage decisions within the family to guide policy in promoting whole family coverage. We analyze the factors that affect individual health insurance coverage among families, and explore family decisions about whom to cover and whom to leave uninsured. The analysis uses household data from California combined with abstracted individual health plan benefit and premium data. We find that premium subsidies for individual insurance would increase family coverage; however, their effect likely would be small relative to their implementation cost.
Effects of Specialty Hospitals on the Financial Performance of General Hospitals, 1997–2004
Authors: Schneider John E. , Ohsfeldt Robert L. , Morrisey Michael A. , Li Pengxiang , Miller Thomas R. , Zelner Bennet A.
Published: August 2011

Hospital specialization has become a controversial topic, culminating in a moratorium issued in 2003 by Congress directing the Centers for Medicare and Medicaid Services to cease payments to new physician-owned specialty hospitals for those Medicare and Medicaid patients referred by physicians with a financial interest in the facility. This paper focuses on one important economic question: does the presence of specialty hospitals in a market affect general hospitals' financial performance? We estimate longitudinal fixed-effects models for a national panel of short-term acute care hospitals for the period 1997 though 2004; models are estimated for general hospital patient-care revenue, costs, and operating margins. We find that the presence of one or more new or established specialty hospitals in a market has a negative effect on general hospital costs and a positive effect on general hospital operating margins. Results, which were consistent across several different modeling approaches, imply that the presence of specialty hospitals encourages greater efficiency on the part of incumbent general hospitals, and the existence of profits attracts market entry. Our findings question the contention that competition from specialty hospitals harms general hospitals financially.
Hospital Inefficiency: What is the Impact of Membership in Different Types of Systems?
Authors: Rosko Michael D. , Proenca Jose , Zinn Jacqueline S. , Bazzoli Gloria J.
Published: August 2011

The primary objective of this study is to assess whether systematic differences in inefficiency are associated with hospital membership in different types of systems. We employed the Battese/Coelli simultaneous stochastic frontier analysis (SFA) technique to estimate hospital cost inefficiency. Mean estimated inefficiency was 8.42%. Membership in different types of systems was related to estimated cost inefficiency (p < .05). Compared to hospitals that were members of centralized health systems, membership in centralized physician/insurance or decentralized systems was associated with decreased inefficiency; membership in independent systems was associated with increased inefficiency.
Genetic Discrimination in Health Insurance: Current Legal Protections and Industry Practices
Authors: Pollitz Karen , Peshkin Beth N. , Bangit Eliza , Lucia Kevin
Published: August 2011

Most states have enacted genetic nondiscrimination laws in health insurance, and federal legislation is pending in Congress. Scientists worry fear of discrimination discourages some patients from participating in clinical trials and hampers important medical research. This paper describes a study of medical underwriting practices in the individual health insurance market related to genetic information. Underwriters from 23 companies participated in a survey that asked them to underwrite four pairs of hypothetical applicants for health insurance. One person in each pair had received a positive genetic test result indicating increased risk of a future health condition—breast cancer, hemochromatosis, or heart disease—for a total of 92 underwriting decisions on applications involving genetic information. In seven of these 92 applications, underwriters said they would deny coverage, place a surcharge on premiums, or limit covered benefits based on an applicant's genetic information.