bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of Memory-Like Autoregulatory CD8+ T Cells Is CD4+ T Cell Dependent
Authors: Shameli Afshin , Clemente-Casares Xavier , Wang Jinguo , Santamaria Pere
Published: August 2011

Progression of spontaneous autoimmune diabetes is associated with development of a disease-countering negative-feedback regulatory loop that involves differentiation of low-avidity autoreactive CD8+ cells into memory-like autoregulatory T cells. Such T cells blunt diabetes progression by suppressing the presentation of both cognate and noncognate Ags to pathogenic high-avidity autoreactive CD8+ T cells in the pancreas-draining lymph nodes. In this study, we show that development of autoregulatory CD8+ T cell memory is CD4+ T cell dependent. Transgenic (TG) NOD mice expressing a low-affinity autoreactive TCR were completely resistant to autoimmune diabetes, even after systemic treatment of the mice with agonistic anti-CD40 or anti–4-1BB mAbs or autoantigen-pulsed dendritic cells, strategies that dramatically accelerate diabetes development in TG NOD mice expressing a higher affinity TCR for the same autoantigenic specificity. Furthermore, whereas abrogation of RAG-2 expression, hence endogenous CD4+ T cell and B cell development, decelerated disease progression in high-affinity TCR-TG NOD mice, it converted the low-affinity TCR into a pathogenic one. In agreement with these data, polyclonal CD4+ T cells from prediabetic NOD mice promoted disease in high-affinity TCR-TG NOD.Rag2−/− mice, but inhibited it in low-affinity TCR-TG NOD.Rag2−/− mice. Thus, in chronic autoimmune responses, CD4+ Th cells contribute to both promoting and suppressing pathogenic autoimmunity.
An inventory of borrow pits and pond development between 1961 to 2005, Highway 3, Yellowknife region, Northwest Territories
Authors: Wolfe S A , Delaney S , Duchesne C
Published: August 2011

This open file provides an inventory of historical borrow pit locations and subsequent pond development formed between 1961 and 2005 along the highway corridor between Behchoko and Yellowknife, Northwest Territories. The inventory and database were prepared to
better understand potential relationships between highway performance and past terrain disturbance that could affect permafrost and geotechnical properties of sediments. The accompanying shapefile format data can be used in a GIS to place areas of borrow pits and recent ponds onto digital maps for
referencing. In addition, files provided in KML format can also be used to locate these areas in Google Earth. The primary purpose of this inventory is to approximate the location and size of historical borrow pits and pond development in relation to highway infrastructure, as a basis for present
and future reference to highway performance in this permafrost-affected terrain.
Utilization patterns of central nervous system drugs: A cross-sectional study among the critically ill patients
Authors: John Lisha Jenny , Devi Padmini , John Jenny , Arifulla Mohamed , Guido Shoba
Published: August 2011

Introduction: Critically ill patients often receive central nervous system drugs due to primary disorder or complications secondary to multiorgan failure. The aim of the study was to evaluate the current utilization pattern of central nervous system drugs among patients in the medical intensive care unit. Materials and Methods: A prospective observational study carried out over a period of 1 year. The relevant data on drug prescription of each patient was collected from the inpatient case record. Drugs were classified into different groups based on WHO–ATC classification. The demographic data, clinical data, and utilization of different classes of drugs as well as individual drugs were analyzed. Results: A total of 325 consecutive patients were included for the analysis; 211 (65%) patients were males; 146 patients (45%) were above 55 years of age. Encephalopathy [63(19.38%)] and stroke [62(19%)] were the common central nervous system diagnoses. In a total of 1237 drugs, 68% of the drugs were prescribed by trade name. Midazolam (N05CD08) 142 (43.69%), morphine (N02AA01) 201 (61.84%), and atracurium (M03AC04) 82 (25.23%) were the most commonly used sedative, analgesic, and neuromuscular blocker, respectively. Phenytoin (N03AB02) 151 (46.46%) had maximum representation among antiepileptic agents. Conclusions: Utilization of drugs from multiple central nervous system drug classes was noticed. Rational use of drugs can be encouraged by prescription by brand name.
Comparison of antinociceptive effect of the antiepileptic drug gabapentin to that of various dosage combinations of gabapentin with lamotrigine and topiramate in mice and rats
Authors: Paudel Keshab Raj , Bhattacharya SK , Rauniar GP , Das BP
Published: August 2011

Introduction: Newer anticonvulsants have a neuromodulatory effect on pain perception mechanisms in a hyperexcitable and damaged nervous system. Aim: This study was designed to study the analgesic effects of gabapentin alone and in combination with lamotrigine and topiramate in experimental pain models. Materials and Methods: Adult albino mice (n = 490) weighing 20–30 g and rats (n = 130) weighing 100–200 g were injected intraperitoneally with gabapentin, lamotrigine, and topiramate alone and in different dose combinations. The hot-plate method, tail-flick method, capsaicin-induced mechanical hyperalgesia, and formalin assay were used to assess the antinociceptive effects. Results: Of the three antiepileptic drugs, when given separately, gabapentin was more efficacious than either topiramate or lamotrigine in all the pain models. Combination of 25 mg/kg gabapentin with 25 mg/kg topiramate was more efficacious (P <.05) than 50 mg/kg gabapentin alone in the capsaicin-induced mechanical hyperalgesia test. Similarly, 50 mg/kg gabapentin with 50 mg/kg topiramate or 5 mg/kg lamotrigine was more efficacious (P <.05) than 50 or 100 mg/kg gabapentin alone in late-phase formalin-induced behaviors. Conclusions: Combination of gabapentin with either lamotrigine or topiramate produced better results than gabapentin alone in capsaicin-induced mechanical hyperalgesia test and in late-phase formalin-induced behaviors.
Role of transcutaneous electric nerve stimulation in the management of trigeminal neuralgia
Authors: Singla Sanju , Prabhakar Vikram , Singla Rajan Kumar
Published: August 2011

Background: Trigeminal neuralgia typically involves nerves supplying teeth, jaws and face of older females. Though the etiology is usually obscure, different treatment modalities have been tried for it viz. medicinal treatment, injection alcohol, peripheral neurectomy, rhizotomy, and microvascular decompression etc. Transcutaneous electric nerve stimulation (TENS) is an emerging and promising option for management of such patients. Aims and Design: The present study was designed with an aim to study the efficacy of TENS in management of trigeminal neuralgia. Materials and Methods: The study was conducted on 30 patients of trigeminal neuralgia confirmed by diagnostic nerve block. They were given bursts of TENS for 20-40 days over the path of the affected nerve and subsequently evaluated at 1 month and 3 month intervals by visual analogue scale (VAS), verbal pain scale (VPS), a functional outcome scales for main daily activities like sleep, chewing, talking, or washing face. Results: The results showed that, on VAS, the score decreased from 8.9 (Pre TENS) to 3.1 at 1 month and 1.3 at 3 months, and on VPS, the score decreased from 3.5 (Pre TENS) to 1.2 at 1 month and 0.3 at 3 months. Similarly, a considerable decrease in scores was seen on functional outcome scale for different activities. No side effects like irritation or redness of skin were seen in any of the patients. Conclusions: Thus, TENS was found to be a safe, easily acceptable, and non-invasive outdoor patient department procedure for management of trigeminal neuralgia.
Airway management for occipital encephalocele in neonatal patients: A review of 17 cases
Authors: Yildirim Zeynep Baysal , Avci Emel , Torun Fuat , Cengiz Mustafa , Çigdem Ali , Karabağ Hamza , Karaman Haktan
Published: August 2011

Introduction: Encephalocele, midline defect of cranial bone fusion, occurs most frequently in the occipital region. Airway management in pediatric patients with craniofacial disorders poses many challenges to the anesthesiologist. The purpose of this study is to describe the airway problems encountered for such cases, and describe how these problems were managed. Materials and Methods: We reviewed the charts of occipital encephalocele newborn that were treated by surgical correction in Harran University Hospital during 2006–2008. The collected data were categorized into preoperative, intraoperative, and postoperative data. Results: The mean age of the patients was 5.17 days. Of these 17 patients, eight patients (47.1%) had hydrocephaly, one patient (5.8%) with Dandy Walker syndrome. Micrognathia, macroglossia, restriction in neck movements were recorded as the reasons in six cases each. No major anesthetic complication was found. Conclusions: We reported perioperative management in 17 occipital encephalocele infant. Comprehensive care during peroperative period is essential for successful outcome.
Unusual features in chronic inflammatory demyelinating polyneuropathy: Good outcome after prolonged ventilatory support
Authors: Jha Sanjeev , Ansari MK , Sonkar KK , Paliwal VK
Published: August 2011

Severe respiratory muscle paralysis and ventilatory failure is rare in chronic inflammatory demyelinating polyneuropathy (CIDP). We report a 14 year child who presented with respiratory failure, bulbar and multiple cranial nerves involvement along with bilateral phrenic nerve paralysis. He was diagnosed with CIDP after electrophysiological evaluation. He required AMBU ventilation for about 4 months (including domiciliary use), after which he recovered significantly. Along with several unusual features of CIDP, this report highlights good example of steady basic intensive care to save lives and rewarding outcome of prolonged respiratory support, provided by AMBU ventilation which is a rather primitive, but inexpensive device.
Occipital artery occlusion to facilitate transmastoid posterior fossa tumor embolization
Authors: Kumar Subhash , Sharma Rohitash , Goyal Sumit , Husain Shakir
Published: August 2011

The transmastoid branch of the occipital artery is an important supply to posterior fossa vascular malformations and tumors and is often difficult to catheterize due to tortuosity and a transforaminal course. In very difficult situations, we can try to induce spasm of the occipital artery just beyond the origin of the mastoid branch by repeated passages of the microcatheter/wire. This induces a temporary ‘ligation’ like effect so that the microcatheter can then be manipulated into the mastoid branch via the mastoid foramen. Rarely, the occipital artery has to be sacrificed if spasm cannot be induced or is short living, following which particles can be injected from a distance without entering the mastoid foramen. Occluding the occipital artery proximally has no effect on distal perfusion, as collaterals and anastomoses from superficial temporal artery, posterior auricular artery, and opposite occipital artery take over the supply.
Bladder distension: An unusual cause of reflux of blood and hemodynamic changes (autonomic dysreflexia) during endovascular coiling
Authors: Sharma DP , Singh Daljit , Ganjoo P , Tandon M
Published: August 2011

Autonomic dysreflexia due to distended bladder is well known. Reflux of blood during endovascular procedure is also a common observation. It happens due to difference in pressure gradient between arterial pressure and that of infusing solution. Generally it happens when the infusion bottle is empty or the pressure in infusion bottles fall. We present an uncommon situation where distended bladder mechanically resulted in reflux of blood into endovascular catheters as well as alteration in hemodynamic parameters. Both settled once the bladder was empty.
Cystic mature teratoma of the thoracic region in a child: An unusual case
Authors: Basmaci Mehmet , Hasturk Askin Esen , Pak Isin
Published: August 2011

Cystic mature teratomas of the spinal cord are rare lesions. Teratomas account for up to 0.1% of all spinal cord tumors. Teratomas include tissues that originate from the three germ layers. Several congenital disorders may accompany the teratoma. Teratomas are classified as mature, immature or malignant type according to their histological characteristics. Thoracic spinal teratomas are uncommon in the pediatric age group. More than half of the patients are adults. We present herein a five-year-old male patient who was referred to our clinic with cystic mature teratoma at the T12 level.
Mania associated with complicated hereditary spastic paraparesis
Authors: Nayak Raghavendra B , Bhogale Govind S , Patil Nanasaheb M , Pandurangi Aditya A
Published: August 2011

Hereditary spastic paraparesis (HSP) is an inherited group of neurological disorders with progressive lower limb spasticity. HSP can be clinically grouped into pure and complicated forms. Pure HSP is one without any associated neurological/psychiatric comorbidity. Depression is the most common psychiatric comorbidity. Presence of mania or bipolar affective illness with HSP is a rare phenomenon. We report a case of a 17-year-old boy who presented with classical features of HSP with complaints of excessive happiness, irritability, increased self-esteem and decreased sleep since 1 month. The patient also had complex partial seizure ever since he had features of HSP. The patient’s father and younger sister suffer from pure HSP. The patient was diagnosed to have first episode mania with complicated HSP. The details of treatment and possible neurobiology are discussed in this case report.
Effectiveness and Tolerability of Methylphenidate in Children and Adolescents with Attention Deficit Hyperactivity Disorder
Authors: Bodey Caroline
Published: August 2011

Attention deficit hyperactivity disorder (ADHD) is a common condition and important for the affected individual, their family and society. It manifests with pervasive symptoms of hyperactivity, impulsivity and inattention. In many children with ADHD these symptoms persist into adolescence and adulthood. Drug treatment with psychostimulants, including methylphenidate, is an important part of a comprehensive treatment plan for children with severe ADHD that includes psychosocial, behavioural and educational advice and interventions. Methylphenidate is a central nervous system stimulant, whose mechanism of action is thought to be due to an increase in catecholamines in areas of the brain concerned with motivation and reward. Methylphendiate is available in short acting (immediate release) and longer acting (modified release) forms. Pharmacotherapy for ADHD is in three stages: initiation, maintenance and termination. The efficacy of methylphenidate in terms of reducing core symptoms is 70% as compared to placebo. This efficacy is maintained for at least 24 months. Methylphenidate generally has a favourable side effect profile. The most significant side effects include appetite suppression with an initial deceleration in height velocity, cardiovascular side effects that are not clinically significant in children with no adverse cardiac history, and tics. Methylphenidate is generally well tolerated and liked by children and adolescents with ADHD, who appreciate the benefits that medication has on their behaviour.
Racial Disparities in Service Use among Medicaid Beneficiaries after Mandatory Enrollment in Managed Care: A Difference-in-Differences Approach
Authors: Tai-Seale Ming , Freund Deborah , LoSasso Anthony
Published: August 2011

Managed care may improve access to health care to previously underserved populations when providers need plan enrollees. However, capitation and utilization management often give providers the incentive to withhold care. Managed care organizations have yet to demonstrate that racial disparities in treatment are not exacerbated. Using Medicaid eligibility, claims, and managed care encounter data, we examine racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care. We use count data models adjusted for nonrandom selection within difference-in-differences econometric approaches. The results show that mandatory enrollment has disproportionately reduced the relative use of physician and inpatient services among African-American beneficiaries.
What Accounts for Differences in Uninsurance Rates across Communities?
Authors: Cunningham Peter J. , Ginsburg Paul B.
Published: August 2011

Using data from the 1996–97 Community Tracking Study household survey, this study examines variations in uninsurance rates across communities in the United States. Specifically, regression-based decomposition is used to identify factors that account for high rates of uninsurance in some communities. Differences in explained rates between “high uninsurance” and “low uninsurance” communities are the result of differences in the racial/ethnic composition and socioeconomic status of the population (33%), differences in employment characteristics (26%), and state Medicaid eligibility requirements (12.7%). Although higher costs are associated with a higher likelihood that individuals are uninsured, high-cost communities tend to have lower rates of uninsurance as a result of other factors. Despite the large number of identifiable factors included in the analysis, there is still a substantial amount of unexplained regional variation in uninsurance rates.
Costs in the Last Year of Life in the Netherlands
Authors: Stooker Tom , van Acht Joost W. , van Barneveld Erik M. , van Vliet René C.J.A. , van Hout Ben A. , Hessing Dick J. , Busschbach Jan J.V.
Published: August 2011

The costs of health care in the last year of life are a subject of debate and myth. Expensive interventions at the end of life often are blamed for the rapid increase in health care spending, but evidence about the existence of such exceptionally high expenditures at the end of life is rare and faulty. This investigation examines the development and composition of health care costs at the end of life for all age groups in The Netherlands. In contrast with earlier studies, this research analyzes both acute care (cure) and long-term care (care) costs. As an alternative for the frequently used concept of calendar years, we employed the concept of life years for calculating the costs at the end of life. We found that when life approaches its end, health care expenditures indeed rise sharply, especially in the last months. However, when we compared total cure costs in the last year of life to the total cure costs for the entire population, we concluded that the end-of-life share was only about 10%. Results of this study show that interventions to reduce costs in the last year of life will have only a modest impact compared to the total health care budget.
Public Subsidies for Employees' Contributions to Employer-Sponsored Insurance
Authors: Merlis Mark
Published: August 2011

Proposals to provide or subsidize health insurance for low-income families must take account of the fact that many workers have access to employer-sponsored insurance (ESI), but decline it because of required employee premium contributions. This article considers a tax credit for the employee share of ESI in the context of a broader program of income-based health insurance tax credits. Helping uninsured workers pay for available ESI could be more cost-effective than subsidizing their coverage in the nongroup market. The credit would also be available to workers who were already covered, both for equity reasons and to reduce the incentives for employers to drop coverage or for workers to shift to subsidized individual plans. One key issue is how to prevent employers from reducing their current health plan contributions to take advantage of the new funding. Other design questions considered by the article include whether workers should be able to choose between ESI and nongroup coverage, whether minimum benefit standards should apply for employer plans, and how to achieve a fair balance in subsidies for group and nongroup coverage.
Expanding Access through Public Coverage: Permitting Families to Use Tax Credits to Buy into Medicaid or SCHIP
Authors: Weil Alan R.
Published: August 2011

A new tax credit to help low-income families and individuals purchase health insurance can address the problem of affordability, but will not overcome other barriers these populations face in obtaining coverage. This paper proposes that families have the option of using a new tax credit to buy into a state-administered system such as Medicaid or the State Children's Health Insurance Program. This option has three advantages. First, it allows families to remain with a single health program and health plan as their income fluctuates. Second, it provides an alternative to the complex and confusing individual insurance market. This alternative is community rated, does not use underwriting, and allows health plan behavior to be monitored closely by the state. Third, it allows the state to act as a financial buffer—helping overcome the barrier to participation that cash-flow problems and year-end reconciliation concerns are likely to create among a low-income population. Many people would want to use their tax credit in the private market, but the buy-in option increases the likelihood that the tax credit approach would succeed.
A Workable Solution for the Pre-Medicare Population
Authors: Short Pamela Farley , Shea Dennis G. , Powell M. Paige
Published: August 2011

Incremental reforms to expand health coverage among older Americans are justified by medical spending that increases with age and enrollment in employer insurance that decreases with age. Older Americans are also at risk of unexpected changes in health, access to health insurance, and earnings that could leave them poorly positioned financially for their retirement years. We propose offering universal access to Medicare at a community-rated premium, with premium vouchers for those with a history of low lifetime earnings and tax-preferred savings accounts to help everyone with the increased cost of insurance at older ages. These subsidies are available for coverage obtained from sources other than Medicare. We would set the eligibility age for the buy-in at 62. However, because enrollment in employer insurance does not drop precipitously at age 62, we regard the eligibility age as an adjustable design element that could resize the program to fit political and budgetary constraints.
Why Don't Private Employers Use Risk Adjustment? Conference Overview
Authors: Glazer Jacob , McGuire Thomas G.
Published: August 2011

In spite of advice from some researchers, private employers do not use formal risk adjustment to pay health plans. A conference, “Private Employers and Risk Adjustment,” was held in February 2000 to consider the meaning of employers' actions. This overview introduces the papers written for that conference.
The Prevalence of Formal Risk Adjustment in Health Plan Purchasing
Authors: Keenan Patricia Seliger , Buntin Melinda J. Beeuwkes , McGuire Thomas G. , Newhouse Joseph P.
Published: August 2011

This paper describes the prevalence of formal risk adjustment of payments made to health plans by Medicare, Medicaid, state governments, and private payers. In this paper, “formal risk adjustment” is defined as the adjustment of premiums paid to health plans based on individual-level diagnostic or demographic information. We find that formal risk adjustment is used for about one-fifth of all enrollees in capitated health plans. While the Medicare and Medicaid programs rely on formal risk adjustment for virtually all their health plan enrollees, the practice is used for only about 1% of privately insured health plan enrollees. Our findings raise the question of why regulators have adopted formal risk adjustment, but private purchasers for the most part have not.
Private Employers Don't Need Formal Risk Adjustment
Authors: Glazer Jacob , McGuire Thomas G.
Published: August 2011

This paper lays down a set of hypotheses to explain why private employers do not use formal risk adjustment. The theme running through these hypotheses is simple: private employers don't need formal adjustment because they have better tools for dealing with adverse selection than formal risk adjustment provides. Open enrollment provisions, premium negotiations, and restricting employees' choices of health plans are mechanisms superior to formal risk adjustment for dealing with problems caused by adverse selection.
Formal Risk Adjustment by Private Employers
Authors: Ellis Randall P.
Published: August 2011

This paper explores explanations for why few private employers have adopted formal risk adjustment. The lack of data, challenges of using highly imperfect signals, and absence of market power are not compelling explanations. Alternative strategies that reduce selection problems are clearly important. The central argument is that U.S. health markets are not in equilibrium, but rather are changing rapidly. Since many agents—consumers, employers, health plans, and providers—do not currently demand formal risk adjustment, it is not surprising that adoption has been slow. Recent changes in health plan markets may change the demand and accelerate future adoption.
Location, Race, and Hospital Care for AIDS Patients: An Analysis of 10 States
Authors: Hellinger Fred J. , Fleishman John A.
Published: August 2011

This study is the first statewide comparison of hospital utilization and inpatient mortality rates for people with acquired immune deficiency syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all people living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the use of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for people with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.
Do Welfare Caseload Declines Make the Medicaid Risk Pool Sicker?
Authors: Garrett Bowen , Holahan John
Published: August 2011

Declining welfare caseloads may lead to a sicker population remaining in the Medicaid program, which could increase per enrollee costs and the level of adequate capitation rates. Using data from the 1997 National Survey of America's Families for adults and children, we examine differences in health status and utilization among welfare recipients and welfare leavers who did and did not retain Medicaid. We adjust utilization differences for insurance status and factors often used to adjust capitation rates. We conclude that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.
Financial Risk Sharing with Providers in Health Maintenance Organizations, 1999
Authors: Gold Marsha R. , Lake Timothy , Hurley Robert , Sinclair Michael
Published: August 2011

The transfer of financial risk from health maintenance organizations (HMOs) to providers is controversial. To provide timely national data on these practices, we conducted a telephone survey in 1999 of a multi-staged probability sample of HMOs in 20 of the nation's 60 largest markets, accounting for 86% of all HMO enrollees nationally. Among those sampled, 82% responded. We found that HMOs' provider networks with physicians, hospitals, skilled nursing homes, and home health agencies are complex and multi-tiered. Seventy-six percent of HMOs in our study use contracts for their HMO products that involve global, professional services, or hospital risk capitation to intermediate entities. These arrangements account for between 24.5 million and 27.4 million of the 55.9 million commercial and Medicare HMO enrollees in the 60 largest markets. While capitation arrangements are particularly common in California, they are more common elsewhere than many assume. The complex layering of risk sharing and delegation of care management responsibility raise questions about accountability and administrative costs in managed care. Do complex structures provide a way to involve providers more directly in managed care, or do they diffuse authority and add to administrative costs?
Doing “Good” vs. Doing “Well”: The Role of Nonprofits in Society
Authors: Berman Howard J.
Published: August 2011

Nonprofit organizations play a unique role in American life. However, they cannot exist alone; they have a complex, interdependent relationship with the economy's two other sectors—business and government. Driving the success of both for-profit and nonprofit organizations is the corporate board. This column explores the dynamics of boards, the connections among the three sectors, and our nation's growing reliance on nonprofits.
A Guide to Comparing Health Care Expenditures in the 1996 MEPS to the 1987 NMES
Authors: Zuvekas Samuel H. , Cohen Joel W.
Published: August 2011

Substantial changes in the organization, delivery, and financing of health care over the last decade, combined with data collection and methodological improvements in the 1996 Medical Expenditure Panel Survey (MEPS), pose special challenges in comparing expenditure estimates in MEPS with those in the 1987 National Medical Expenditure Survey (NMES). The 1987 NMES used charges as its fundamental expenditure concept, whereas the 1996 MEPS used actual payments as its expenditure measure. In spite of these differences, researchers and policymakers will want to be able to analyze trends in health care expenditures using these two surveys. We discuss these issues in detail and present a simple, straightforward adjustment method that can be applied to the 1987 NMES public use expenditure data to improve comparability to the MEPS. We base this adjustment method on an analysis of provider-reported payment data collected in NMES. We present several examples of the application of this method that illustrate the importance of the adjustments for analyses of trends in health care spending.
Small Firms' Demand for Health Insurance: The Decision to Offer Insurance
Authors: Hadley Jack , Reschovsky James D.
Published: August 2011

This paper explores the decisions by small business establishments (<100 workers) to offer health insurance. We estimate a theoretically derived model of establishments' demand for insurance using nationally representative data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey and other sources. Findings show that offer decisions reflect worker demand, labor market conditions, and establishments' costs of providing coverage. Premiums have a moderate effect on offer decisions (elasticity = –.54), though very small establishments and those employing low-wage workers are more responsive. This suggests that premium subsidies to employers would be an inefficient means of increasing insurance coverage. Greater availability of public insurance and safety net care has a small negative effect on offer decisions.
Advancing the Role of Nonprofit Health Care
Authors: Metcalfe Marcia
Published: August 2011

This article comes out of a series of discussions among a diverse group of chief executive officers (CEOs) and other leaders of nonprofit hospitals, long-term care facilities, health maintenance organizations, and other insurance providers, including several nonprofit Blue Cross Blue Shield (BCBS) plans. The group was convened as part of Howard Berman's Walter J. McNerney Fellowship project. (Berman is CEO of Excellus, Inc., a nonprofit Blue Cross Blue Shield affiliate that insures the health of more than 2.15 million people in upstate New York. He was awarded the McNerney Fellowship in April 2001 by the Health Research and Educational Trust, an American Hospital Association affiliate. The Fellowship goes annually to at least one fellow to highlight or pursue work that will provide new insights into how different sectors of the health care system can better work together for improved outcomes.) The group has met several times over the past year around a shared concern: the current challenges to nonprofit health care organizations and the future role for nonprofits in the re-visioning and creation of an American health care system that is characterized by universal access, patient-centered quality, and national affordability. Members have supported the public relations campaign of the “Alliance for Advancing Nonprofit Health Care,” an effort initiated by the Caucus, an independent group of nonprofit BCBS plans. The group continues to explore the need for a broad-based coalition of providers, insurers, and other organizations to effectively protect and enhance the role of nonprofit health care.
Managed Care: An Industry Snapshot
Authors:   The Harvard Managed Care Industry Center Group
Published: August 2011

Together with the American Association of Health Plans (AAHP), we surveyed health maintenance organizations (HMOs) in 1998 to characterize their basic structure and management strategies. The findings show that more than half of HMO enrollees belong to plans that contract with primary care physician (PCP) groups on a predominantly capitated basis. Such plans tend to be larger and to contract with large physician groups. Thirty percent to 40% of enrollees are in plans that delegate utilization and network management to physician groups paid by capitation, but plans almost never delegate these functions to groups paid by fee-for-service. Plans tend to retain quality assurance functions irrespective of whether they use fee-for-service or capitation as a basis for physician payment. The autonomy of PCPs to order tests and procedures varies with the test and procedure.
Participation in a Public Insurance Program: Subsidies, Crowd-Out, and Adverse Selection
Authors: Long Stephen H. , Marquis M. Susan
Published: August 2011

This paper examines how varying the level of subsidies affects participation in a public insurance program, crowd-out of private insurance, and adverse selection. We study the experience in Washington's Basic Health program in 1997. Findings show that adverse selection is not a problem in voluntary public programs. Increasing subsidies have only modest effects on participation in subsidized programs, though the gains are not at the expense of the private market. Overall participation in the subsidized plan is also modest, even though participants benefit from it. The challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.
Does Informal Care from Adult Children Reduce Nursing Home Admissions for the Elderly?
Authors: Lo Sasso Anthony T. , Johnson Richard W.
Published: August 2011

Despite the policy importance, particularly as society ages, little is known about the impact of informal care on nursing home admissions. This paper jointly models the receipt of regular help from adult children and subsequent nursing home care, using data from the Study of Asset and Health Dynamics Among the Oldest Old (AHEAD). Results indicate that frequent help from children with basic personal care reduces the likelihood of nursing home use over a subsequent two-year period by about 60% for disabled Americans age 70 and older. However, we found no significant reduction in nursing home admissions when help was measured more broadly to include assistance with chores and errands.
Hospital Advertising in California, 1991–1997
Authors: Town Robert J. , Currim Imran
Published: August 2011

This paper examines the advertising behavior of California hospitals from 1991 to 1997. Using highly detailed hospital-level information, we found that hospital advertising in California increased dramatically: annual spending on advertising grew (inflation adjusted) more than sixfold over the period. In addition, advertising expenditures varied significantly across hospitals. We found that hospital advertising increased with market concentration; with the number of nearby potential patients; with the percentage of nearby patients insured through Medicare, health maintenance organizations (HMOs), and indemnity insurance; and with chain affiliation. For-profit hospitals were not found to advertise more than their not-for-profit counterparts.
Productivity vs. Training in Primary Care: Analysis of Hospitals and Health Centers in New York City
Authors: DeLia Derek , Cantor Joel C. , Duck Elaine
Published: August 2011

This paper examines the indirect costs of primary care residency in terms of ambulatory care site productivity and the influence of graduate medical education (GME) subsidies on the employment of primary care residents. Using a sample of hospitals and health centers in New York City (NYC), we find that most facilities employ significantly more primary care residents relative to nonresident primary care physicians than would be dictated by cost-minimizing behavior in the production of primary care. We also find evidence that New York's GME subsidy encourages the “overemployment” of residents, while the Medicare GME subsidy does not. We conclude that the trade-off between productivity and teaching is more serious in primary care than in inpatient settings, and that facilities heavily involved in ambulatory care teaching will be at a competitive disadvantage if GME subsidies are not targeted specifically for primary care.
An Examination of Factors in the Withdrawal of Managed Care Plans from the Medicare+Choice Program
Authors: Glavin Mitchell P.V. , Tompkins Christopher P. , Wallack Stanley S. , Altman Stuart H.
Published: August 2011

Participation of health maintenance organizations (HMOs) in the Medicare +Choice program, expected to rise rapidly after passage of the Balanced Budget Act of 1997, has gone in just the opposite direction. Because plans have left in such large numbers, Congress has taken remedial measures to remove restrictions and increase payments. To date these efforts have failed. This paper uses plan organizational characteristics, market position, and financial performance to quantify the reasons why some HMOs exited at the end of 1998. The findings suggest HMO participation in Medicare +Choice will continue to fall unless major changes are made to the overall Medicare program and the method of paying HMOs.
Ownership and Changes in Hospital Inefficiency, 1986–1991
Authors: McKay Niccie L. , Deily Mary E. , Dorner Fred H.
Published: August 2011

This study examines how ownership affected changes in hospital inefficiency after the introduction of prospective payment by Medicare. Using a national data set, we estimate cost frontiers for 1986 and 1991 to assess hospitals' efficiency relative to best practice in both those years. We then use regression analysis to determine the effect of ownership on the change in hospitals' efficiency. The results indicate that, in both 1986 and 1991, mean inefficiency was highest for for-profit hospitals and lowest for not-for-profit hospitals, with government hospitals falling in the middle. Moreover, between 1986 and 1991, both for-profit and government hospitals had significantly less improvement in efficiency than not-for-profit hospitals, all else equal.
How Many Hospital Beds?
Authors: Green Linda V.
Published: August 2011

For many years, average bed occupancy level has been the primary measure that has guided hospital bed capacity decisions at both policy and managerial levels. Even now, the common wisdom that there is an excess of beds nationally has been based on a federal target of 85% occupancy that was developed about 25 years ago. This paper examines data from New York state and uses queueing analysis to estimate bed unavailability in intensive care units (ICUs) and obstetrics units. Using various patient delay standards, units that appear to have insufficient capacity are identified. The results indicate that as many as 40% of all obstetrics units and 90% of ICUs have insufficient capacity to provide an appropriate bed when needed. This contrasts sharply with what would be deduced using standard average occupancy targets. Furthermore, given the model's assumptions, these estimates are likely to be conservative. These findings illustrate that if service quality is deemed important, hospitals need to plan capacity based on standards that reflect the ability to place patients in appropriate beds in a timely fashion rather than on target occupancy levels. Doing so will require the collection and analysis of operational data—such as demands for and use of beds, and patient delays—which generally are not available.
Adverse Selection and Generosity of Alcohol Treatment Benefits
Authors: Harris Katherine M. , Sturm Roland
Published: August 2011

Concerns about attracting disproportionate numbers of employees with alcohol problems limit employers' willingness to offer health plans with generous alcohol treatment benefits. This paper analyzes two potential avenues of adverse selection, namely biased enrollment into plans and biased exit from plans offered by 57 employers between 1991 and 1997. We compare alcohol treatment use rates and costs of new and old enrollees between more generous and less generous plans; we also analyze disenrollment rates and enrollment duration by plan generosity for users and nonusers of alcohol treatment services. To avoid confounding benefit generosity with other plan features, in particular the use of managed care mechanisms, we compare plans that were administered in the same way by a large managed behavioral health care organization. Overall, we find no evidence of adverse selection into more generous plans. Contrary to the selection hypothesis, treatment costs of new members compared to old members are lower in firms with more generous treatment benefits than in firms with more limited benefits. Also, users of alcohol treatment services do not remain disproportionately enrolled longer in plans with generous benefits.
U.S. Hospital Industry Restructuring and the Hospital Safety Net
Authors: Bazzoli Gloria J. , Manheim Larry M. , Waters Teresa M.
Published: August 2011

The U.S. hospital industry was reshaped during the 1990s, with many hospitals becoming members of health systems and networks. Our research examines whether safety net hospitals (SNHs) were generally included or excluded from these arrangements, and the factors associated with their involvement. Our analysis draws on the earlier work of Alexander and Morrisey (1988), and not only studies factors affecting SNH participation in multihospital arrangements but also updates their earlier study. We constructed measures for hospital market conditions, management, and mission, and examined network and system affiliation patterns between 1994 and 1998. Our findings suggest that larger and more technically advanced hospitals joined systems in the 1990s, which contrasts with 1980s findings that smaller, financially weak institutions joined systems. Further, SNH participation in networks and systems was more common when hospitals faced less market pressure and where only a limited number of unaffiliated hospitals remained. If networks and systems are key parties in negotiating with private payers, SNHs may be going it alone in these negotiations in highly competitive markets.
Patterns of Health Care and Disability for Medicare Beneficiaries under 65
Authors: Riley Gerald F. , Lubitz James D. , Zhang Nancy
Published: August 2011

Disabled people under age 65 are a vulnerable and growing segment of the Medicare population, yet Medicare reform has focused on the needs of the aged. This study linked the Medicare Current Beneficiary Survey to Social Security Administration records to analyze patterns of health care for disabled beneficiaries by reason for disability. We found substantial variation in average health care costs by type of service, including prescription drugs, and in sources of payment. Rates of institutionalization were high among some disability categories and there was heavy reliance on Medicaid and other public programs for payment. It is essential that the special needs of the disabled not be overlooked as policymakers consider fundamental modifications to Medicare and Medicaid.
Hospital-Based and Freestanding Skilled Nursing Facilities: Any Cause for Differential Medicare Payments?
Authors: Liu Korbin , Black Kirsten J.
Published: August 2011

Differential Medicare payments for hospital-based and freestanding skilled nursing facilities (SNFs) were eliminated by the SNF prospective payment system initiated in 1998. Closures and high negative margins of hospital-based facilities have prompted consideration of the need to revisit payment adjustments for this group of SNFs. We examine case mix-related and other factors behind the cost differences between hospital-based and freestanding SNFs. Some payment adjustment, notably for nontherapy ancillary services, may be reasonable for the short term.
Coverage Gaps for Medicaid-Eligible Children in the Wake of Federal Welfare Reform
Authors: Haley Jennifer , Kenney Genevieve
Published: August 2011

Using data from the National Survey of America's Families, this paper examines insurance coverage changes for Medicaid-eligible citizen children between 1997 and 1999, early in the implementation of federal welfare reform. More than 20 million children qualified for Medicaid, but many were uninsured. Insurance coverage deteriorated for eligible children between 1997 and 1999, particularly for those who also qualified for cash assistance; this deterioration in coverage was largely due to dramatic declines in cash assistance participation. This paper shows that following federal welfare reform, states have faced new challenges reaching and enrolling the growing numbers of eligible children who are not connected with the welfare system.
State Variation in SCHIP Allocations: How Much is There, What are its Sources, and Can it Be Reduced?
Authors: Davern Michael , Blewett Lynn A. , Bershadsky Boris , Call Kathleen Thiede , Rockwood Todd
Published: August 2011

Allocations for the State Children's Health Insurance Program (SCHIP) varied 22% per state between 1999 and 2002. The funding fluctuations present significant problems for states as they develop budget priorities under difficult fiscal conditions. We examine sources of the variation in state allocations during the first four years of SCHIP, focusing on the Current Population Survey's “child component” of the allocation formula. We consider the trade-offs in using alternative estimates from the American Community Survey and model-based estimation. Obtaining reliable estimates of need for SCHIP allocations is critical for states dependent on federal support for insurance programs.
Medical Vulnerability in America: How Does the Health System Respond?
Authors: Knickman James R. , Hunt Kelly A.
Published: August 2011

This study explores the hypothesis that market change affects the medically vulnerable more than the non-medically vulnerable. Analysis of data measuring change between 1997 and 1999 indicates that access to care eroded for both groups, but no evidence emerges to suggest that the changes were systematically worse for the medically vulnerable. Paradoxically, some measures of satisfaction with actual care received improved between 1997 and 1999 for both groups of people. Recent market changes do not seem to pose extra special threats to the medically vulnerable. However, our findings reinforce the need to better coordinate and integrate services for the medically vulnerable and chronically ill.