bluuebunny/crossref_metadata_2025 huggingface dataset:
Death Spiral or Euthanasia? The Demise of Generous Group Health Insurance Coverage
Authors: Pauly Mark V. , Mitchell Olivia S. , Zeng Yuhui
Published: August 2011

Employers must determine the types of health care plans to offer and also set employee premiums for each plan provided. Depending on the structure of the employee share of premiums across different health insurance plans, the incentives to choose one plan over another are altered. If employees know premiums do not fully reflect the risk differences among workers, such pricing can give rise to a so-called “death spiral” due to adverse selection. This paper uses longitudinal information from a natural experiment in the management of health benefits for a large employer to explore the impact of moving from a fixed-dollar contribution policy to a partially risk-adjusted employer contribution policy. Our results show that implementing a significant risk adjustment had no discernable effect on adverse selection against the most generous indemnity insurance policy. This stands in stark contrast to previous studies, which have tended to estimate large impacts attributed to selection when employers move to a fixed-dollar policy from one with some risk adjustment. Further analysis suggests that previous studies, which appeared to detect plans in the throes of a death spiral, may instead have been reflecting an inexorable movement away from a non-preferred product, one that would have been inefficient for nearly all workers even in the absence of adverse selection.
Premium Increases in State Health Insurance Programs: Lessons from a Case Study of the Massachusetts Medicaid Buy-in Program
Authors: Livermore Gina A. , Goodman Nanette , Hooven Fred , Hashemi Lobat
Published: August 2011

In March 2003, Massachusetts increased the premiums it charges to most enrollees in its CommonHealth-Working (CH-W) program. This study evaluates the impact of the premium change on disenrollment using a comparison group methodology. The findings indicate that the premium change had only a small, but statistically significant impact on program exits. The CH-W experience differs from other state programs that saw substantial enrollment declines in response to new or increased premiums. This is likely due to factors that make CH-W different from other programs, key of which are administrative procedures intended to minimize disenrollment due to premium nonpayment.
The Accuracy of Reported Insurance Status in the MEPS
Authors: Hill Steven C.
Published: August 2011

Estimates of the number of insured and uninsured Americans are watched by numerous policymakers and the public, yet studies find respondents do not report their insurance status perfectly. Using four sources of validation data, including surveys of employers and providers, this paper assesses the quality of respondents' reports of private insurance and uninsurance in the Medical Expenditure Panel Survey Household Component (MEPS-HC), a nationally representative household survey. Regression analysis is used to assess the extent to which factors are associated with disagreements in reported insurance status across sources.
Health-Based Risk Adjustment: Improving the Pharmacy-Based Cost Group Model by Adding Diagnostic Cost Groups
Authors: Prinsze Femmeke J. , van Vliet René C. J. A.
Published: August 2011

Since 1991, risk-adjusted premium subsidies have existed in the Dutch social health insurance sector, which covered about two-thirds of the population until 2006. In 2002, pharmacy-based cost groups (PCGs) were included in the demographic risk adjustment model, which improved the goodness-of-fit, as measured by the R2, to 11.5%. The model's R2 reached 22.8% in 2004, when inpatient diagnostic information was added in the form of diagnostic cost groups (DCGs). PCGs and DCGs appear to be complementary in their ability to predict future costs. PCGs particularly improve the R2 for outpatient expenses, whereas DCGs improve the R2 for inpatient expenses. In 2006, this system of risk-adjusted premium subsidies was extended to cover the entire population.
The Market for Long-Term Care Services
Authors: Grabowski David C.
Published: August 2011

Although a large literature has established the importance of market and regulatory forces within the long-term care sector, current research in this field is limited by a series of data, measurement, and methodological issues. This paper provides a comprehensive review of these issues with an emphasis on identifying initiatives that will increase the volume and quality of long-term care research. Recommendations include: the construction of standard measures of long-term care market boundaries, the broader dissemination of market and regulatory data, the linkage of survey-based data with market measures, the encouragement of further market-based studies of noninstitutional long-term care settings, and the standardization of Medicaid cost data.
Managed Care and Hospital Cost Containment
Authors: Konetzka R. Tamara , Zhu Jingsan , Sochalski Julie , Volpp Kevin G.
Published: August 2011

This study assesses the ability of managed care to contain hospital costs since the managed care backlash, using data from California's Office of Statewide Health Planning and Development for all acute-care hospitals in the state for the period 1991–2001. The analysis employs a long-differences design to examine cost growth before and after the managed care backlash. Results from the early 1990s are consistent with prior evidence that the combination of more competitive markets and high managed care penetration held down costs. Post-backlash, high managed care penetration no longer was associated with lower cost growth in the most competitive markets, indicating that the synergistic effects between managed care and hospital competition no longer may exist.
Health Care Coalitions: From Joint Purchasing to Local Health Reform
Authors: Camillus Joseph A. , Rosenthal Meredith B.
Published: August 2011

For several decades, business and health coalitions have played an important role in representing the interests of business in the health care arena. During the 1990s, these coalitions focused their efforts on supporting purchasing activities related to health insurance benefits and direct health care. Based on a national survey conducted in 2006, and prior similar surveys, we find that business and health coalitions have invested in pooling regional health care data, promoting public reporting of quality and cost information, and coordinating pay-for-performance initiatives. In addition, many business and health coalitions are broadening their membership to include other stakeholders and to support community health reform efforts with far-reaching benefits. Through this work, coalitions increasingly are recognizing and embracing their role as catalysts for local market reform.
Health Insurance Enrollment Decisions: Preferences for Coverage, Worker Sorting, and Insurance Take-up
Authors: Monheit Alan C. , Vistnes Jessica Primoff
Published: August 2011

The weak response by the uninsured to initiatives encouraging voluntary enrollment in health insurance has raised concerns regarding the extent to which the uninsured value insurance. This concern is also relevant for proposals to mandate health insurance coverage since workers will suffer welfare losses if compelled to purchase coverage they perceive to be of little value. To address this issue, we use the 2001 Medical Expenditure Panel Survey to examine decisions by single workers to seek out and enroll in employer-sponsored insurance. We find that single workers with weak or uncertain preferences for health insurance are less likely to have jobs that offer coverage or to enroll in coverage when offered. Our results suggest a dual approach to expanding coverage that includes both subsidies and educational efforts regarding the value of health insurance.
Health Supervision Visits among SSI-Eligible Children in the D.C. Medicaid Program: A Comparison of Enrollees in Fee-for-Service and Partially Capitated Managed Care
Authors: Mitchell Jean M. , Gaskin Darrell J. , Kozma Chahira
Published: August 2011

Managed care plans that involve some form of capitation may have adverse effects on children with special health care needs because the financial incentives to control costs may result in under-treatment and restrict access to expensive services and specialty providers. Proponents highlight the advantages of a managed care model, including case management and coordination of services. In light of this debate, only a few state Medicaid programs have implemented a managed care option for children with special health care needs. This study evaluates the effects of plan choice (partially capitated managed care versus fee-for-service) on whether children with disabilities eligible for Supplemental Security Income (SSI) and enrolled in the District of Columbia's Medicaid program are in compliance with the guidelines for health supervision visits established by the American Academy of Pediatrics (AAP). Our findings, based on five years of claims data, show that SSI-eligible children with disabilities enrolled in a partially capitated managed care plan are significantly more likely to be in compliance with the AAP guidelines for health supervision visits compared to their fee-for-service counterparts. Moreover, we find that selection due to unobservable characteristics does not significantly bias the estimated program effects.
Association of Market, Operational, and Financial Factors with Nonprofit Hospitals' Capital Investment
Authors: Kim Tae Hyun , McCue Michael J.
Published: August 2011

Capital investments in the latest medical equipment and the replacement of aging facilities are critical decisions for sustaining hospitals' financial viability. A recent survey over the period 1997 to 2001 found that hospitals increased their capital expenditures by only 1%. The aim of this study is to gain insight into the changes in market, operational, and financial factors that may have influenced hospital capital investment during this period. The sample consisted of a panel of nonprofit hospitals operating between 1998 and 2001. Capital investment was measured on the basis of capital purchases for buildings, fixtures, and movable equipment during a fiscal year. The results suggest that liquidity—the availability of internal funds—is a critical determinant of capital investment in both urban and rural facilities. From a market perspective, findings indicate that growth in the over-65 population led to increases in the capital investment of rural hospitals. Financially, an increase in cash flow also was strongly related to a change in capital investment among urban facilities. Surprisingly, rural hospitals with aging plants and equipment had declining capital investment.
Variation in Patients' Hospice Costs
Authors: Huskamp Haiden A. , Newhouse Joseph P. , Norcini Jessica Cafarella , Keating Nancy L.
Published: August 2011

We obtained patient-level cost data from one hospice to explore variation in hospice costs across patients. We found that average per day costs decreased as duration of hospice stay increased. Costs per day were lower for nursing home residents than nonresidents. We identify possible alterations to the Medicare per diem payment system that could address these issues, including higher per diems for the first and last days and an adjuster for nursing home residence. However, replicating these results using data from a broader, more representative sample of hospices is needed before making changes to the per diem system.
The Effects of Hospital Competition on Inpatient Quality of Care
Authors: Mutter Ryan L. , Wong Herbert S. , Goldfarb Marsha G.
Published: August 2011

Existing empirical studies have produced inconclusive, and sometimes contradictory, findings on the effects of hospital competition on inpatient quality of care. These inconsistencies may be due to the use of different methodologies, hospital competition measures, and hospital quality measures. This paper applies the Quality Indicator software from the Agency for Healthcare Research and Quality to the 1997 Healthcare Cost and Utilization Project State Inpatient Databases to create three versions (i.e., observed, risk-adjusted, and “smoothed”) of 38 distinct measures of inpatient quality. The relationship between 12 different hospital competition measures and these quality measures are assessed, using ordinary least squares, two-step efficient generalized method of moments, and negative binomial regression techniques. We find that across estimation strategies, hospital competition has an impact on a number of hospital quality measures. However, the effect is not unidirectional: some indicators show improvements in hospital quality with greater levels of competition, some show decreases in hospital quality, and others are unaffected. We provide hypotheses based on emerging areas of research that could explain these findings, but inconsistencies remain.
The Price Effect of Hospital Closures
Authors: Wu Vivian Y.
Published: August 2011

This paper analyzes the anti-competitive effect of hospital closures between 1993 and 1998. Using a modified rival analysis with difference-in-differences (DD) and difference-in-difference-in-differences (DDD) identification strategies, this study finds that competitors located nearest to closed hospitals were best able to improve their bargaining position. Moreover, rivals that experienced multiple neighborhood closures, that faced large closures relative to their own sizes, and that were located in more concentrated markets were all able to raise prices even more. The overall estimate suggests a 4%, one-time, permanent price increase due to closure, a strong price effect that has been overlooked in the literature.
Hospital Staffing Decisions: Does Financial Performance Matter?
Authors: Zhao Mei , Bazzoli Gloria J. , Clement Jan P. , Lindrooth Richard C. , Nolin JoAnn M. , Chukmaitov Askar S.
Published: August 2011

This study assesses the impact of changes in hospitals' financial conditions on changes in hospitals' staffing decisions. The sample consisted of community hospitals operating between 1995 and 2000. The analysis employed a generalized method of moments (GMM) estimator for its dynamic panel data. Cash flow and patient margin were used to measure financial condition. We estimated the effect of changing financial condition on the number of full-time equivalent personnel (FTEs), registered nurses (RNs), and licensed practical nurses (LPNs) per 1,000 adjusted patient days. Our results suggest that declining financial performance led to cutbacks in LPN FTEs per adjusted patient day, but the effects on total hospital FTEs and RN FTEs were mixed.
New Evidence on the Effects of State Mental Health Mandates
Authors: Busch Susan H. , Barry Colleen L.
Published: August 2011

State mental health parity laws improve equity in private insurance coverage for mental and physical health services, but prior research shows no effect on service use. We study whether state parity differentially affects individuals by employer size since large firms are often exempt from state health mandates due to the Employee Retirement Income Security Act. We also examine whether state parity laws differentially affect use among individuals with low incomes or in poor mental health. We find that individuals in smaller firms are more likely to use services post-parity implementation and that this effect is concentrated among low-income individuals.
Differences in Breast Cancer Diagnosis and Treatment: Experiences of Insured and Uninsured Women in a Safety-Net Setting
Authors: Bradley Cathy J. , Neumark David , Shickle Lisa M. , Farrell Nicholas
Published: August 2011

To explore how well the safety net performs at eliminating differences in diagnosis and treatment of insured and uninsured women with breast cancer, we compared insured and uninsured women treated in a safety-net setting. Controlling for socioeconomic characteristics, uninsured women are more likely to be diagnosed with advanced disease, requiring more extensive treatment relative to insured women, and also experience delays in initiating and completing treatment. The findings suggest that, despite the safety-net system, uninsured women with breast cancer are likely to require more costly treatment and to have worse outcomes relative to insured women with breast cancer.
What Do People Buy When They Don't Buy Health Insurance and What Does That Say about Why They are Uninsured?
Authors: Levy Helen , DeLeire Thomas
Published: August 2011

Using data from the Consumer Expenditure Survey, this study compares household spending on different goods by insured versus uninsured households, controlling for total spending and demographic characteristics. The analysis shows that uninsured households, on average, spend more on housing, food, alcohol, and tobacco compared to insured households. These results suggest that both prices and preferences, in addition to income, help explain why some households do not buy coverage; the findings also raise the possibility that the uninsured may lack coverage in part because they face higher prices for basic needs like housing and food.
Does Managed Care Improve Access to Care for Medicaid Beneficiaries with Disabilities? A National Study
Authors: Coughlin Teresa A. , Long Sharon K. , Graves John A.
Published: August 2011

States increasingly are shifting Medicaid beneficiaries with disabilities from the fee-for-service (FFS) delivery system to managed care in an effort to control program costs and address long-standing problems with access to care under the program. Using a county-based measure of managed care enrollment and pooled data from the 1997 to 2004 National Health Interview Surveys, we investigate whether Medicaid managed care (MMC), relative to FFS Medicaid, improves access to care. We find some evidence of improved access to care under MMC; however, the gains appear to be largely limited to beneficiaries in urban areas with fully capitated managed care. There is little evidence of improved access under primary care case management or, regardless of MMC type, in rural areas.
Cancer Survivorship, Health Insurance, and Employment Transitions among Older Workers
Authors: Tunceli Kaan , Short Pamela Farley , Moran John R. , Tunceli Ozgur
Published: August 2011

This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997–2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of jobrelated health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.
Effect of Prescription Drug Coverage on the Elderly's Use of Prescription Drugs
Authors: Khan Nasreen , Kaestner Robert
Published: August 2011

This paper evaluates the effect of prescription drug insurance coverage on prescription drug use among the elderly. Estimates were obtained using multivariate regression and a fixed-effects (within-person) research design that controls for unmeasured person-specific effects that may confound the relationships of interest. Estimates showed prescription drug coverage was associated with a 4% to 10% increase in the utilization of prescription drugs, depending on the type and generosity of the coverage.
Converting to Critical Access Status: How Does it Affect Rural Hospitals' Financial Performance?
Authors: Li Pengxiang , Schneider John E. , Ward Marcia M.
Published: August 2011

To improve rural access to care, the Balanced Budget Act of 1997 allowed eligible rural hospitals to convert to critical access hospitals (CAHs), which changed their Medicare payment from a prospective payment system (PPS) to a cost-based system. The objective of this paper is to examine the effects of CAH conversion on rural hospital operating revenues, operating expenses, and operating margins using an eight-year panel of 89 rural hospitals in Iowa. Ad hoc hospital revenue, cost, and profit functions were estimated using panel data fixed-effects linear models. We found that rural hospital CAH conversion was associated with significant increases in hospital operating revenues, expenses, and margins.
Accuracy of Medicare Expenditures in the Medical Expenditure Panel Survey
Authors: Zuvekas Samuel H. , Olin Gary L.
Published: August 2011

This paper examines underreporting and underrepresentation of high expenditure cases in the Medical Expenditure Panel Survey (MEPS) and their implications for analyses. Our data come from a sample of Medicare beneficiaries in the MEPS who were matched to their Medicare claims and enrollment files, with supplemental data from the Medicare Current Beneficiary Survey (MCBS). Underreporting of expenditures affected all groups of Medicare beneficiaries in the matched sample, but uniformly so that behavioral analyses were largely unaffected. Straightforward adjustments to the MEPS expenditure estimates could align them with aggregate sources, such as the National Health Expenditure Accounts, while preserving underlying relationships between expenditures and key correlates.
The Accountability of Nonprofit Hospitals: Lessons from Maryland's Community Benefit Reporting Requirements
Authors: Gray Bradford H. , Schlesinger Mark
Published: August 2011

Under Internal Revenue Service requirements, nonprofit hospitals will begin filing new community benefit reports in 2010. Maryland has had similar requirements since 2004. This paper, based on interviews at 20 hospitals, describes how Maryland's requirements affected hospitals and their activities. Increases in reported community benefit expenditures since the program began are due to both changes in activities and better data capture. Charity care accounts for one-third of community benefit dollars. A key distinction concerns whether hospitals take an accounting or managerial approach to community benefit. The Maryland experience suggests the issues that will arise when the national requirements are implemented.
Does High Caregiver Stress Predict Nursing Home Entry?
Authors: Spillman Brenda C. , Long Sharon K.
Published: August 2011

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.
Single Specialty Hospitals and Service Competition
Authors: Carey Kathleen , Burgess James F. , Young Gary J.
Published: August 2011

Advocates for physician-owned hospitals specializing in cardiac, orthopedic, and surgical services claim that these facilities induce healthy competition, stimulating improved performance among acute care hospitals. This paper examines the effect of specialty hospital entry on one indicator of competition among hospitals: changes in service provision by general hospitals in local markets. Results suggest that general hospitals are stepping up their own offerings of services that are in direct competition with those of specialty hospitals. Entry of specialty hospitals is also associated with significantly higher growth in high-technology diagnostic imaging services in the general hospitals in those markets.
Quality-Based Payment for Medical Groups and Individual Physicians
Authors: Robinson James C. , Shortell Stephen M. , Rittenhouse Diane R. , Fernandes-Taylor Sara , Gillies Robin R. , Casalino Lawrence P.
Published: August 2011

This paper measures the extent to which medical groups experience external pay-for-performance incentives based on quality and patient satisfaction and the extent to which these groups pay their primary care and specialist physicians using similar criteria. Over half (52%) of large medical groups received bonus payments from health insurance plans in the period 2006–2007 based on measures of quality and patient satisfaction. Medical groups facing external pay-for-performance incentives are more likely to pay their primary care physicians (odds ratio [OR] 4.5; p<.001) and specialists (OR 2.5; p=.07) based on quality and satisfaction. Groups facing capitation payment incentives to control costs are more likely to pay member physicians on salary and less likely to pay based on productivity (p<.001 for primary care; p<.05 for specialists) than groups paid by insurers on a fee-for-service basis.
Employer-Sponsored Health Insurance and the Promise of Health Insurance Reform
Authors: Buchmueller Thomas C. , Monheit Alan C.
Published: August 2011

The central role that employers play in financing health care is a distinctive feature of the U.S. health care system, and the provision of health insurance through the workplace has important implications well beyond its role as a source of health care financing. In this paper, we consider the “goodness of fit” of employer-sponsored health insurance (ESI) in the current economic and health insurance environments and in light of prospects for a vigorous national debate over the shape of health care reform. The main issue that we explore is whether ESI can have a viable role in health system reform efforts or whether such coverage will need to be significantly modified or even abandoned as reform seeks to address important issues in the efficient provision and equitable distribution of health insurance coverage.
Mandates and the Affordability of Health Care
Authors: Glied Sherry
Published: August 2011

This paper examines the economic rationale of affordability exemptions in the context of a health insurance mandate. I provide an economic definition of affordability and discuss how it is implemented in the contexts of food, housing, and health care. Affordability standards are frequently used in making food and housing policy, but both empirically and theoretically health care operates quite differently than these other merit goods. This helps explain why the use of affordability in health policymaking is so different from its use in these other contexts. I conclude with some suggestions about how to improve affordability exemption rules in health policymaking.
Beneficial Moral Hazard and the Theory of the Second Best
Authors: Frick Kevin D. , Chernew Michael E.
Published: August 2011

This article examines the welfare consequences of moral hazard, and brings together several arguments suggesting that, in many cases, the additional consumption associated with health insurance could be welfare enhancing. Since conditions for maximum economic efficiency fail to hold in the market for medical care, the theory of the second best is useful. We focus on three efficiency-related reasons why insurance-induced consumption may improve welfare: 1) insurance can offset market power; 2) insurance can remedy some externalities; and 3) insurance can mitigate problems that are associated with misinformation and result in the underutilization of many types of care. These arguments strengthen the case for expanding coverage.
Aspects of Health Reform: Contributions from the Economic Research Initiative on the Uninsured. Aspects of Health Reform: Introduction
Authors: McLaughlin Catherine , Levy Helen , Quinn Brian
Published: August 2011

From 2001 to 2008, the Robert Wood Johnson Foundation funded the Economic Research Initiative on the Uninsured (ERIU), housed at the University of Michigan. The goals of ERIU were to increase, diversify, and improve the quality and quantity of economics research on the uninsured, and to translate that research into the type of resources that are useful to policymakers, policy analysts, researchers, and members of the media.

One of the primary objectives of ERIU was to fund research projects that explored economic issues about the uninsured in new, yet rigorous and interesting ways. ERIU began by commissioning six critical syntheses of the existing research. These syntheses were intended to inform researchers of what we know and what we don't know about the uninsured. In eight years, ERIU funded more than 50 new research projects on a variety of coverage topics aimed at addressing the gaps in knowledge highlighted in these syntheses. These projects, involving more than 100 researchers, resulted in over 70 conference and seminar presentations worldwide and approximately 40 articles published in peer-reviewed journals.
Risk Selection and Risk Adjustment: Improving Insurance in the Individual and Small Group Markets
Authors: Baicker Katherine , Dow William H.
Published: August 2011

Insurance market reforms face the key challenge of addressing the threat that risk selection poses to the availability of stable, high-value insurance policies that provide long-term risk protection. Many of the strategies in use today fail to address this breakdown in risk pooling, and some even exacerbate it. Flexible risk adjustment schemes are a promising avenue for promoting market stability and limiting insurer cream-skimming, potentially providing greater benefits at lower cost. Reforms intended to increase insurance coverage and the value of care delivered will be much more effective if implemented in conjunction with policies that address these fundamental selection issues.
The Effect of Medicaid Expansions on the Health Insurance Coverage of Pregnant Women: An Analysis Using Deliveries
Authors: Dave Dhaval M. , Decker Sandra L. , Kaestner Robert , Simon Kosali Ilayperuma
Published: August 2011

Using data from the National Hospital Discharge Survey, this paper analyzes the effect of Medicaid eligibility expansions from 1985 to 1996 on the health insurance coverage of women giving birth. We find that the eligibility expansions reduced the proportion of pregnant women who were uninsured by approximately 10%, although the magnitude of this decrease is sensitive to specification. The decrease in the proportion of uninsured pregnant women came at the expense of a substantial reduction in private insurance coverage (crowd-out) of at least 55%. Substantial crowd-out and the relatively small change in the proportion uninsured suggest that Medicaid eligibility expansions may have had small effects on infant and maternal health.
Trends in Unionization of Nursing Homes
Authors: Sojourner Aaron J. , Grabowski David C. , Chen Min , Town Robert J.
Published: August 2011

Unionization may have important implications for the delivery of nursing home care, but little is known about this phenomenon. Since 1985, the proportion of nursing home workers covered by union contracts declined from 14.6% to 9.9%. The first national-scale data on facility-level unionization reveals that unions are more common in nursing homes with more residents, in hospital-based or chain-affiliated facilities, and in facilities serving a higher proportion of Medicaid patients. With new federal policy proposals aimed at substantially lowering the cost of organizing workers, policymakers will want to consider the potential impact of nursing home unionization on worker, patient, and market outcomes.
Prior Use of Durable Medical Equipment as a Risk Adjuster for Health-Based Capitation
Authors: van Kleef Richard C. , van Vliet René C. J. A.
Published: August 2011

This paper examines a new risk adjuster for capitation payments to Dutch health plans, based on the prior use of durable medical equipment (DME). The essence is to classify users of DME in a previous year into clinically homogeneous classes and to apply the resulting classification as a risk adjuster for capitation payments in the subsequent year. We evaluate 143 DME types in terms of incentives, validity, predictive value, and measurability, resulting in 14 functional disability classes (FDCs). We conclude that FDCs can significantly improve the Dutch risk adjustment model, although possible incentives for oversupply have to be monitored.
Two instruments based on differential optical absorption spectroscopy (DOAS) to measure accurate ammonia concentrations in the atmosphere
Authors: Volten H. , Bergwerff J. B. , Haaima M. , Lolkema D. E. , Berkhout A. J. C. , van der Hoff G. R. , Potma C. J. M. , Wichink Kruit R. J. , van Pul W. A. J. , Swart D. P. J.
Published: August 2011

Abstract. We present two Differential Optical Absorption Spectroscopy (DOAS) instruments built at RIVM, the RIVM DOAS and the miniDOAS. Both instruments provide virtually interference free measurements of NH3 concentrations in the atmosphere, since they measure over an open path, without suffering from inlet problems or interference problems by ammonium aerosols dissociating on tubes or filters. They measure concentrations up to at least 200 μg m−3, have a fast response, low maintenance demands, and a high up-time. The RIVM DOAS has a high accuracy of typically 0.15 μg m−3 for ammonia over 5-min averages and over a total light path of 100 m. The miniDOAS has been developed for application in measurement networks such as the Dutch National Air Quality Monitoring Network (LML). Compared to the RIVM DOAS it has a similar accuracy, but is significantly reduced in size, costs, and handling complexity. The RIVM DOAS and miniDOAS results showed excellent agreement (R2 = 0.996) during a field measurement campaign in Vredepeel, the Netherlands. This measurement site is located in an agricultural area and is characterized by highly variable, but on average high ammonia concentrations in the air. The RIVM-DOAS and miniDOAS results were compared to the results of the AMOR instrument, a continuous-flow wet denuder system, which is currently used in the LML. Averaged over longer time spans of typically a day the (mini)DOAS and AMOR results agree reasonably well, although an offset of the AMOR values compared to the (mini)DOAS results exists. On short time scales the (mini)DOAS shows a faster response and does not show the memory effects due to inlet tubing and transport of absorption fluids encountered by the AMOR. Due to its high accuracy, high uptime, low maintenance and its open path, the (mini)DOAS shows a good potential for flux measurements by using two (or more) systems in a gradient set-up and applying the aerodynamic gradient technique.
The new WMO RA VI Regional Climate Centre Node on Climate Monitoring
Authors: Rapp J. , Nitsche H. , Bissolli P.
Published: August 2011

Abstract. Regional Climate Centres are institutions with the capacity and mandate by WMO to develop high quality regional-scale products using global products, national input and incorporating regional information. Recently a pilot network of three Regional Climate Centre consortia was established for the WMO region RA VI (Europe and Middle East). Germany (Deutscher Wetterdienst) has taken the responsibility of the Regional Climate Centre Node on Climate Monitoring. The main basic functions of this centre are the publication of annual and monthly climate diagnostic bulletins, monthly monitoring maps, monitoring of significant events, implementation of a climate watch system, capacity building and offering reference climatologies and trend maps.
Blastodinium spp. infect copepods in the ultra-oligotrophic marine waters of the Mediterranean Sea
Authors: Alves-de-Souza C. , Cornet C. , Nowaczyk A. , Gasparini S. , Skovgaard A. , Guillou L.
Published: August 2011

Abstract. Blastodinium are chloroplast-containing dinoflagellates which infect a wide range of copepods. They develop inside the gut of their host, where they produce successive generations of sporocytes that are eventually expelled through the anus of the copepod. Here, we report on copepod infections in the oligotrophic to ultra-oligotrophic waters of the Mediterranean Sea sampled during the BOUM cruise. Based on a DNA-stain screening of gut contents, 16 % of copepods were possibly infected in samples from the Eastern Mediterranean infected, with up to 51 % of Corycaeidae, 33 % of Calanoida, but less than 2 % of Oithonidae and Oncaeidae. Parasites were classified into distinct morphotypes, with some tentatively assigned to species B. mangini, B. contortum, and B. cf. spinulosum. Based upon the SSU rDNA gene sequence analyses of 15 individuals, the genus Blastodinium was found to be polyphyletic, containing at least three independent clusters. The first cluster grouped all sequences retrieved from parasites of Corycaeidae and Oncaeidae during this study, and included sequences of Blastodinium mangini (the "mangini" cluster). Sequences from cells infecting Calanoida belonged to two different clusters, one including B. contortum (the "contortum" cluster), and the other uniting all B. spinulosum-like morphotypes (the "spinulosum" cluster). Cluster-specific oligonucleotidic probes were designed and tested by fluorescence in situ hybridization (FISH) in order to assess the distribution of dinospores, the Blastodinium dispersal and infecting stage. Probe-positive cells were all small thecate dinoflagellates, with lengths ranging from 7 to 18 μm. Maximal abundances of Blastodinium dinospores were detected at the Deep Chlorophyll Maximum (DCM) or slightly below. This was in contrast to distributions of autotrophic pico- and nanoplankton, microplanktonic dinoflagellates, and nauplii which showed maximal concentrations above the DCM. The distinct distribution of dinospores and nauplii argues against infection during the naupliar stage. Dinospores, described as autotrophic in the literature, may escape the severe nutrient limitation of ultra-oligotrophic ecosystems by living inside copepods.
Distribution of epipelagic metazooplankton across the Mediterranean Sea during the summer BOUM cruise
Authors: Nowaczyk A. , Carlotti F. , Thibault-Botha D. , Pagano M.
Published: August 2011

Abstract. The diversity and distribution of epipelagic metazooplankton across the Mediterranean Sea was studied along a 3000 km long transect from the eastern to the western basins during the BOUM cruise in summer 2008. Metazooplankton were sampled using both a 120 μm mesh size bongo net and Niskin bottles in the upper 200 m layer at 17 stations. Here we report on the stock, the composition and the structure of the metazooplankton community. The abundance was 4 to 8 times higher than in several previously published studies, whereas the biomass remained within the same order of magnitude. An eastward decrease in abundance was evident, although biomass was variable. Spatial (horizontal and vertical) distribution of metazooplankton abundance and biomass was strongly correlated to chlorophyll-a concentration. In addition, a clear association was observed between the vertical distribution of nauplii and small copepods and the depth of the deep chlorophyll maximum. The distinction between the communities of the eastern and western basins was clearly explained by the environmental factors. The specific distribution pattern of remarkable species was also described.
The strength of the biotic compartment to retain nitrogen additions prevents nitrogen losses from a Mediterranean maquis
Authors: Dias T. , Martins-Loução M. A. , Sheppard L. , Cruz C.
Published: August 2011

Abstract. Nitrogen (N) is one of the nutrients most limiting to ecosystem productivity. However, N availability is increasing globally, which may affect ecosystem functions and stability. To understand the role of each ecosystem compartment in the cycling of increased N, we studied the initial response of a nutrient-poor ecosystem, a Mediterranean maquis, to increased N. N availability (dose and forms) was modified by three N additions along the year (spring, summer and middle autumn/winter). Soil inorganic N pools (nitrate in particular) strongly reflected the N additions in autumn, almost matching the total N added along the three additions. Cistus ladanifer, the dominant plant species, responded to the increased N (cover and N concentration in leaves and litter), and given that leaf shedding occurs in the summer, the importance of this N pool returning to the soil through litter decomposition on the total soil inorganic N in autumn was investigated. Data suggest that living plants and litter have a crucial role in preventing N losses from Mediterranean maquis. This is the first integrated field study on how European Mediterranean ecosystems retain increased N of different forms and doses, however longer-term studies are needed to explore the generality of this study's observations.
Johann Christian Heuson, a little-known auroral scholar of the early 18th century
Authors: Schlegel K. , Silverman S.
Published: August 2011

Abstract. Heuson published two booklets of observations of the aurora of 17/18 February, 1/2 March 1721, and 16/17 November 1729 together with contemporary thoughts about the subject. His work characterizes him as a well-educated scholar familiar with contemporary auroral observations and theories. Heuson rejects views of the aurora as an omen or portent of divine wrath, but explains the aurora as a natural phenomenon and is thus in line with other well-known auroral scholars of that time.
Biofeedback, Meditation, and Mindfulness
Authors: Edwards Lawrence
Published: August 2011

Biofeedback has its beginnings in research conducted on yogis and Zen masters decades ago. Research shows the pervasive positive impact that meditative and mindfulness practices have on individuals. Mindfulness-based practices have been taken out of their broader contexts—extracted from deeper systems of yogic and Buddhist disciplines. Clinicians need to be aware of the unintended consequences of divorcing these practices from their original systems. Biofeedback, meditation, and mindfulness training share important techniques for effecting positive changes.
Yoga as Therapy in Psychiatric Disorders: Past, Present, and Future
Authors: Gangadhar B. N , Varambally Shivarama
Published: August 2011

Complementary and alternative medical treatment, yoga therapy in particular, is being increasingly used for treating psychiatric disorders. Although some claim that such a time-tested practice, yoga, does not need validation, standards of contemporary medical practice make it necessary to test these treatments through modern evidence-based research methods. This paper discusses yoga as a therapy in medical and psychiatric disorders, the challenges that it faces in becoming accepted by the general medical community, and directions for future research in this area.
State-Enlivening and Practice-Makes-Perfect Approaches to Meditation
Authors: Shear Jonathan
Published: August 2011

Meditation procedures can have different types of effects and operate by very different mechanisms. Effects of Mindfulness and Vipassana procedures are often closely akin to what the meditators do in meditation and are understood as emerging via practice-makes-perfect mechanisms. Effects of major procedures from Zen and Transcendental Meditation (TM), by contrast, are often very different from what the meditators do in meditation and are traditionally understood as arising from states enlivened by the meditation techniques, rather than practice-makes-perfect mechanisms. Intensely concentrative γ-electroencephalogram (EEG)–related Zen koan work and effortless ά-related use of mantras in TM are reported to produce the same basic state of pure consciousness/emptiness and types of out-of-meditation effects. These include enhancement of activities incompatible with, rather than expressions of, the activities of the procedures said to produce them. Numerous studies of the TM technique support these observations. They show, for example, enhancement of highly focused, concentrative activities (academic performance, reaction-time, etc.) that are so different from the effortless, explicitly focus-eschewing, ά-associated activity of TM that they are regularly referred to as “ά-blocking.” Such effects do not appear to be explainable as practice-makes-perfect effects. Psychological, gross-physiological, and EEG-related mechanisms have been proposed to explain how state-enlivening procedures might produce their effects.
Growing Interest in Meditation in the United States
Authors: Burke Adam , Gonzalez Autumn
Published: August 2011

Meditation is a self-regulatory, mind-body process used to help engage attention and awareness, and to produce a state of inner quiescence. It has been used as a self-transformative practice for millennia, most notably in the Far East. Interest in meditation was evident in the United States in the late 19th century, and began to flourish during the early 1960s as Transcendental Meditation, Zen, and other traditions grew significantly in popularity. Over the ensuing decades a large body of scientific literature has also emerged. One factor contributing to this growth in publications is an increasingly sophisticated ability to measure brain activity using functional magnetic resonance imaging (fMRI) and advance EEG and MEG technologies. National surveys, including the National Health Interview Survey's (NHIS), also show clear evidence of growing consumer interest in meditation. The NHIS shows use of meditation to be in the top ten most commonly used complementary and alternative medicine (CAM) therapies. The most recent 2007 NHIS compared findings of meditation use with reported use in the 2002 survey. A statistically significant increase in mediation practice among adults in the previous 12 months was noted, up from 7.6% in 2002 to 9.4% in 2007.
Plasma Nitriding of Surface Mo-Enriched Sintered Iron
Authors: Bendo T. , Pavanati H. C. , Klein A. N. , Martinelli A. E. , Maliska A. M.
Published: August 2011

Plain iron samples produced by powder metallurgy were submitted to a single thermal cycle involving plasma-assisted sintering and simultaneous surface alloying with Mo followed by nitriding using a plasma reactor. The microstructural characterization of the samples was carried out by optical and scanning electron microscopy in addition to X-ray diffraction. Microhardness tests were also performed. EDX line profiles of the concentration of Mo from the surface to the bulk of the sintered samples showed that the alloying element diffused down to depths of about 25 μm under the sintering conditions applied. A significant increase in microhardness was observed for samples enriched with Mo and subsequently nitrided. This behavior was attributed to the precipitation of nitrides and the presence of Mo in solid solution.
The Recurrent Vulvovaginal Candidiasis: Proposal of a Personalized Therapeutic Protocol
Authors: Murina F. , Graziottin A. , Felice R. , Radici G. L. , Di Francesco S.
Published: August 2011

Background. Recurrent vulvovaginal candidiasis (RVC) is an increasing challenge in clinical practice. Objective. The purpose of this study was to reduce the episodes of RVC through the intake of fluconazole 200 mg/dose with a personalized regimen at growing administration intervals with a probiotic. Method. 55 patients received a 200 mg fluconazole as an induction dose for 3 alternate days. Symptoms resolution after 10–14 days made the patients eligible to continue with a maintenance therapy of fluconazole weekly for one month, followed by 200 mg after 10, 15, 20 and 30 days. Patients were allowed to move on to the next level of maintenance therapy only if they were symptom free. Patients were also given a probiotic with Beta Glucan and Echinacea Purpurea. Results. Among the 55 patients enrolled, four (7%) have withdrawn after the induction phase. 51 patients completed the whole therapeutic maintenance period, and eight (15,6%) experienced a recurrence before the end of the therapy. Five women (9,8%) relapsed (two after 2 months and three after 6 months). Conclusion. The positive results of our study prove the effectiveness of an individualized protocol for a rather short period, with a slowly decreasing administration of fluconazole + probiotic.