bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study
Authors: Levitt Joseph E , Vinayak Ajeet G , Gehlbach Brian K , Pohlman Anne , Van Cleve William , Hall Jesse B , Kress John P
Published: January 2008

Introduction

Distinguishing pulmonary edema due to acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) from hydrostatic or cardiogenic edema is challenging in critically ill patients. B-type natriuretic peptide (BNP) can effectively identify congestive heart failure in the emergency room setting but, despite increasing use, its diagnostic utility has not been validated in the intensive care unit (ICU).

Methods

We performed a prospective, blinded cohort study in the medical and surgical ICUs at the University of Chicago Hospitals. Patients were eligible if they were admitted to the ICU with respiratory distress, bilateral pulmonary edema and a central venous catheter suggesting either high-pressure (cardiogenic) or low-pressure (ALI/ARDS) pulmonary edema. BNP levels were measured within 48 hours of ICU admission and development of pulmonary edema and onward up to three consecutive days. All levels were drawn simultaneously with the measurement of right atrial or pulmonary artery wedge pressure. The etiology of pulmonary edema – cardiogenic or ALI/ARDS – was determined by three intensivists blinded to BNP levels.

Results

We enrolled a total of 54 patients (33 with ALI/ARDS and 21 with cardiogenic edema). BNP levels were lower in patients with ALI/ARDS than in those with cardiogenic edema (496 ± 439 versus 747 ± 476 pg/ml, P = 0.05). At an accepted cutoff of 100 pg/ml, specificity for the diagnosis of ALI/ARDS was high (95.2%) but sensitivity was poor (27.3%). Cutoffs at higher BNP levels improved sensitivity at considerable cost to specificity. Invasive measures of filling pressures correlated poorly with initial BNP levels and subsequent day BNP values fluctuated unpredictably and without correlation with hemodynamic changes and net fluid balance.

Conclusion

BNP levels drawn within 48 hours of admission to the ICU do not reliably distinguish ALI/ARDS from cardiogenic edema, do not correlate with invasive hemodynamic measurements, and do not track predictably with changes in volume status on consecutive daily measurements.
Early Events in the Pathogenesis of Epithelial Ovarian Cancer
Authors: Landen Charles N. , Birrer Michael J. , Sood Anil K.
Published: January 2008

Ovarian carcinogenesis, as in most cancers, involves multiple genetic alterations. A great deal has been learned about proteins and pathways important in the early stages of malignant transformation and metastasis, as derived from studies of individual tumors, microarray data, animal models, and inherited disorders that confer susceptibility. However, a full understanding of the earliest recognizable events in epithelial ovarian carcinogenesis is limited by the lack of a well-defined premalignant state common to all ovarian subtypes and by the paucity of data from early-stage cancers. Evidence suggests that ovarian cancers can progress both through a stepwise mutation process (low-grade pathway) and through greater genetic instability that leads to rapid metastasis without an identifiable precursor lesion (high-grade pathway). In this review, we discuss many of the genetic and molecular disorders in each key process that is altered in cancer cells, and we present a model of ovarian pathogenesis that incorporates the role of tumor cell mutations and factors in the host microenvironment important to tumor initiation and progression.
Predictors of Contralateral Prophylactic Mastectomy in Women With a BRCA1 or BRCA2 Mutation: The Hereditary Breast Cancer Clinical Study Group
Authors: Metcalfe Kelly A. , Lubinski Jan , Ghadirian Parviz , Lynch Henry , Kim-Sing Charmaine , Friedman Eitan , Foulkes William D. , Domchek Susan , Ainsworth Peter , Isaacs Claudine , Tung Nadine , Gronwald Jacek , Cummings Shelly , Wagner Teresa , Manoukian Siranoush , Møller Pål , Weitzel Jeffrey , Sun Ping , Narod Steven A.
Published: January 2008

Purpose

To evaluate the rate of prophylactic contralateral mastectomy in an international cohort of women with hereditary breast cancer and to evaluate the predictors of uptake of preventive surgery.

Patients and Methods

Women with a BRCA1 or BRCA2 mutation who had been diagnosed with unilateral breast cancer were followed prospectively for a minimum of 1.5 years. Information was collected on prophylactic surgery, tamoxifen use, and the occurrence of contralateral breast cancer.

Results

Nine hundred twenty-seven women were included in the study; of these, 253 women (27.3%) underwent a contralateral prophylactic mastectomy after the initial diagnosis of breast cancer. There were large differences in uptake of contralateral prophylactic mastectomy by country, ranging from 0% in Norway to 49.3% in the United States. Among women from North America, those who had a prophylactic contralateral mastectomy were significantly younger at breast cancer diagnosis (mean age, 39 years) than were those without preventive surgery (mean age, 43 years). Women who initially underwent breast-conserving surgery were less likely to undergo contralateral prophylactic mastectomy than were women who underwent a mastectomy (12% v 40%; P < 10−4). Women who had elected for a prophylactic bilateral oophorectomy were more likely to have had their contralateral breast removed than those with intact ovaries (33% v 18%; P < 10−4).

Conclusion

Age, type of initial breast cancer surgery, and prophylactic oophorectomy are all predictive of prophylactic contralateral mastectomy in women with breast cancer and a BRCA mutation. The acceptance of contralateral preventive mastectomy was much higher in North America than in Europe.
Regulating Physician Supply: The Evolution of British Columbia's Bill 41
Authors: Barer Morris L.
Published: January 2008

This paper traces the development of British Columbia's controversial Bill 41, which empowers that province's Ministry of Health to restrict the issuance of billing numbers entitling physicians to seek payment from the provincial medical services plan. The bill and its predecessors have been the subjects of two court challenges by the medical profession, and the legal battles continue. The bill has also taken on a role in the evolving interpretation of Canada's new Charter of Rights and Freedoms. Meanwhile, the policy appears to be slowing the rate of growth in physician supply in the province, but its impact on the real targetmedical care costs is still uncertain.
Applying Antitrust Concepts to the Acute Care Hospital Industry: Defining the Relevant Market for Hospital Services
Authors: Klingensmith James M.
Published: January 2008

In considering the possible antitrust implications of a merger of two or more competing hospitals, the courts have generally found that hospitals provide a cluster of services which have significant peculiar characteristics that allow them to be considered a single product market. Spurred by changes in their environments, hospitals during the last decade have become markedly less homogeneous in their range of products and geographic markets. As a result, the impact of hospital mergers in the future may need to be assessed in multiple, more narrowly defined relevant markets, for which several possible definitional bases are suggested in this paper. The increased precision associated with such multidimensional antitrust analysis should permit a more effective consideration of the trade-offs between increases in hospitals' market power and advances in their relative operating efficiency and/or quality of services.
Improving the Quality and Quantity of Whole Blood Supply: Limits to Voluntary Arrangements
Authors: Roberts Russell D. , Wolkoff Michael J.
Published: January 2008

The inadvertent transmission of AIDS virus through contaminated whole blood has shaken the viability of the American voluntary blood supply system. For the first time since the voluntary donor system replaced the commercial blood system, there are widespread doubts about the ability of blood suppliers to meet the nation's increasing health care demands. This paper presents a framework for analyzing blood collection. First, we critique the existing literature on blood collection, arguing that its focus on donor motivation is difficult to integrate with policy analysis. We then present a specific model of the individual's decision to donate blood as a comparison of the costs and benefits of donating. The current system of collecting whole blood relies on donors receiving only altruistic benefits. We explore the limits of this approach to dealing with the quantity and quality problems presented by the AIDS virus. Alternative approaches to blood collection which allow personal benefitssuch as donor designation or monetary paymentsmay be necessary to supply the nation's blood demands in the future.
National Planning for Locally Controlled Health Systems: The Finnish Experience
Authors: Saltman Richard B.
Published: January 2008

The World Health Organization considers Finland's health planning system to be among the most successful in the developed world. Despite tight resource constraintssymbolized by total health expenditures held consistently to less than 7 percent of gross domestic productthe Finns have built up a strong primary care sector and dramatically improved the overall availability and accessibility of needed services. This article compares the official health planning system with the actual planning process as experienced within one Finnish central hospital district. The official planning system seeks to integrate national strategic goals with local municipal ownership, administration, and funding of service delivery. The actual planning process within the studied district suggests that technically oriented civil servants at the regional level may be at least as important in the overall decisionmaking structure. The article concludes with a brief exploration of this finding's potential consequences for the long-term development of the Finnish health care system and for national health planning efforts generally.
Competition among Health Insurers, Revisited
Authors: Frech H. E. , Ginsburg Paul B.
Published: January 2008

This paper updates our 1977 study of health insurance competition. We find that insurers are now far more willing to compete by controlling costs. Large consumer copayments and insurer utilization controls, once deemed politically in-feasible, have become commonplace. HMOs and especially PPOs are booming. Blue Shield and Blue Cross market share and market power are declining. We discuss why the insurance market has changed and conclude with thoughts on the future.
Halfway Competitive Markets and Ineffective Regulation: The American Health Care System
Authors: Altman Stuart H. , Rodwin Marc A.
Published: January 2008

Since the late 1960s the U.S. has attempted to develop a strategy for controlling the rate of growth of health care spending. During the 1970s this strategy relied heavily on various forms of regulation. Some regulatory programs were partially successful in moderating spending increases, but they generated significant oppositionparticularly from powerful provider groups, who successfully convinced Congress and the states to dismantle most of the regulatory structure and to substitute various forms of competitive approaches to controlling spending. Some of these competitive strategies have been successful in increasing the efficiency of subsections of our health system. But they too have produced “losers,” and the government has been pressured to enter the system to minimize their losses. The net result has been a political stalemate between halfway competitive markets and ineffective regulation. With the rate of health care spending growth near historic levels, it is likely that the 1990s will bring a return to a stronger role for government regulation. But it is unlikely that we are any more willing to tolerate the negative fallout from regulation today than we were in the 1970s, and therefore we predict that the proportion of GNP going to health care will continue to grow throughout the remainder of this century.
Labor Union Involvement in Occupational Safety and Health, 1957–1987
Authors: Robinson James C.
Published: January 2008

Right-to-know policies and related market-oriented occupational health policies require an institutionalized means through which workers can interpret and act on information about quality differences among jobs. In principle, labor unions could play this role. However, union coverage has been declining since the 1950s, and the decline has accelerated in recent years. This paper documents the growth in occupational health and safety activities in unionized workplaces from 1957 to 1987 and the decline in union representation in hazardous workplaces from 1971 to 1986. It also analyzes the relationship between right-to-know and right-to-refuse-hazardous-work guarantees under industrial relations and occupational health law.
The Role of Substitutes in Policy Analysis: Acute Care Services in State Medicaid Programs
Authors: Miller Mark
Published: January 2008

Using four acute care equations (inpatient, physician, outpatient, and clinic) from a larger model of Medicaid, this research examines the “contents” of policy outcomes. This closer examination of outcomes brings to light the interactions between redistributive programs and services and the role of substitutes and complements in state-level policy analysis. (A substitute is a benefit or service that can be used instead of another to produce a similar outcome; a complement is a benefit or service that is likely to result in the use of another benefit or service.) Support is found for the inclusion of these theoretical constructs in policy analysis. Regarding Medicaid, the author concludes that physician, outpatient, and clinic services all complement hospital services; that physician and outpatient services substitute for one another; that state AFDC and SSI policy decisions have a greater impact on utilization than Medicaid-specific eligibility and service decisions do; and that the factors driving utilization (supply, demand, etc.) vary dramatically across acute care settings. The implications for Medicaid policymaking are also discussed.
A Profile of Medicaid Home and Community-Based Care Waivers, 1985: Findings of a National Survey
Authors: Laudicina Susan S. , Burwell Brian
Published: January 2008

This article presents the findings of a national survey of Medicaid home and community-based care waiver programs established under Section 2176 of the Omnibus Budget Reconciliation Act of 1981. The article documents the ways states have used their waiver authority, the methods states use to target their programs to people who are at risk of institutionalization, the programs' service utilization and expenditure levels, and the quality assurance systems that have been established as of 30 September 1985. Based on these state-reported descriptions of Medicaid home and community-based waiver programs, the article discusses preliminary findings on the cost-effectiveness of the waivers and looks at some potential attributes of a cost-effective program.
Home Blood Transfusions: The Medical, Economic, and Legal Issues Surrounding a New Treatment Procedure
Authors: Koepke Mark D. , Nyman John A. , Koepke John A.
Published: January 2008

Blood transfusions have almost always been confined to hospital settings in the past. Recent medical care trends have shifted some therapies (e.g., renal dialysis, hemophilia treatment) into the patient's home. Transfusions are now being given in increasing numbers to stable patients in their homes. This paper examines the medical aspects, the economic issues, and the legal implications of such transfusions. Candidates for home transfusion must be carefully chosen primarily according to the medical guidelines for such treatment. Any legal issues must be satisfactorily answered before approval is given. The paper concludes that if done properly, home transfusions can be safe, cost-effective, and convenient for a carefully selected segment of patients.
AIDS Testing and Informed Consent
Authors: Swartz Martha S.
Published: January 2008

This article examines whether hospitals should obtain specific informed consent for HIV testing in addition to the general consent for routine procedures that is obtained upon admission. The article argues that specific consent should be obtained in all instances in which the HIV test is ordered. When the test is ordered to protect health care workers rather than to benefit the patient, the patient must be informed of the true purpose of the test; special care must be taken to avoid claims of fraud or duress that might invalidate the patient's consent. Furthermore, testing patients for the sole purpose of protecting health care workers should be discouraged, since the protection of health care workers can already be accomplished through universal blood and bodily fluid precautions. In balancing the inconvenience caused by universal blood and bodily fluid precautions against the privacy rights of patients, the patients' rights should prevail.
Making Sense of Referral Fee Statutes
Authors: Hall Mark A.
Published: January 2008

State and federal prohibitions of referral fees have long plagued the health care sector because their broadly worded provisions threaten established and socially valuable business arrangements. Congress has recently instructed the Department of Health and Human Services to issue regulations that clarify the scope of the most threatening of these prohibitions, the Medicare and Medicaid felony referral fee statute. This article examines three possible analytical models for imposing a limiting construction on referral fee statutes by testing the models against three beneficial practices that the statute jeopardizes: physician recruitment, fee discounting, and efficiency bonuses. The article recommends primary reliance on an earned/unearned analysis that detects a prohibited referral fee by asking whether the fee is fully earned by legitimate, nonreferral services.
Toward a Definitive Antitrust Standard for Nonprofit Hospital Mergers
Authors: Kopit William G. , McCann Robert W.
Published: January 2008

Despite decades of federal and state regulatory efforts to encourage more efficient utilization of hospital resources, recent federal antitrust enforcement actions assert that nonprofit hospital mergers are detrimental to consumers. This policy, however, is derived from misguided attempts to apply the economic assumptions of for-profit industries to the nonprofit hospital sector and to extend statutes enacted to restrain national economic concentration to local nonprofit enterprises. This paper concludes that a rational antitrust enforcement policy that recognizes the unique characteristics of hospital markets can be described within the confines of existing antitrust statutes.
PPS Waivers: Implications for Medicare, Medicaid, and Commercial Insurers
Authors: Zuckerman Stephen , Holahan John
Published: January 2008

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they “go alone.” Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.
Going to Court: The Experience of Child Victims of Intrafamilial Sexual Abuse
Authors: King Nancy M. P. , Hunter Wanda M. , Runyan Desmond K.
Published: January 2008

Concerned about the possible detrimental impact of the investigative process and court proceedings on child victims of sexual abuse, many child advocates have proposed extensive evidentiary and procedural revisions of the court process. As part of a long-term study of the effects of child sexual abuse on the victims' mental health, we observed child sexual abuse victims during juvenile and criminal court proceedings. Although it was clear to our observers that going to court was stressful for these children, it was not clear that the only effective way of reducing their stress would be to avoid “live” testimony. We propose that many simple improvements for example, increasing the involvement of guardians ad litem, providing adequate time to prepare the child for court, reducing the number of continuances granted, and training attorneys and judges to deal effectively with child witnesseswould be less costly and less controversial to implement than closed-circuit or videotaped testimony, new hearsay exceptions, and other more extensive proposals for change.
Gas Taxes and Motor Vehicle Fatalities
Authors: Leigh J. Paul , Frank Arthur L.
Published: January 2008

Economists view taxes as a more efficient means of reducing the consumption of a product than regulation. They have therefore suggested raising cigarette and alcohol taxes to reduce the undesirable effects of tobacco and alcohol on the public's health. This essay suggests that a gasoline tax can have similar beneficial influences on reducing highway deaths and injuries. Moreover, if some proceeds of the tax are used to finance mass transit, the regressiviry of the tax can be ameliorated.
Is There a Rationale for Regionalizing Organ Transplantation Services?
Authors: Sloan Frank A. , Shayne May W. , Doyle Marilyn D.
Published: January 2008

This paper explores issues in the designation of centers to provide organ transplantation procedures and aftercare, a decision faced increasingly by policymakers, planners, and payers. As background for consideration of the regionalization of organ transplantation services, an array of models of regionalization of health services, ranging from full-scale vertical integration to market-enhancing information provision, is described. In the United States, regionalization has mainly followed the designation model within the certificate-of-need system; vertical integration has been adopted only in limited ways. Next, the authors' review of current approaches to the regionalization of organ transplantation centers by public and private payers indicates that designation of centers is increasing, although the empirical evidence concerning the classes of hospitals upon which designation decisions rest is weak. The authors then review the literature on the relationship between volumes and outcomes on surgical services with particular reference to organ transplantation, which on the whole suggests that a relationship between volumes and outcomes exists. Original empirical analysis of data on kidney transplants that were secured from the Health Care Financing Administration is then presented. The study of the effects of hospital and surgeon volumes on graft and patient survival and of the effect of volume on charges found no systematic influence of hospital or surgeon volumes on graft or patient survival. Some evidence that charges are lower for larger centers was found. The authors conclude that the evidence implies that using volume as the provider characteristic upon which to base designation of transplantation centers is problematic, at least for kidney transplants. Steps policymakers might take to ensure quality of transplantation services is discussed in the final section.
Government Funding for Organ Transplants
Authors: Schuck Peter H.
Published: January 2008

This paper examines the role of the federal and state governments in paying for organ transplants. The first section, descriptive in nature, presents data on the past, current, and projected payment patterns for different kinds of organ transplants under various federal and state programs. The second section, which is normative, considers the three principal arguments for and against government payment for organ transplants. These arguments revolve around efficiency, equity, and communitarian claims, and none of them is wholly satisfactory. The final section, which is policy-oriented, assumes that government financing of organ transplants will continue but will be fiscally constrained, and goes on to analyze a number of important payment policy issues in the light of broader principles. These issues relate to eligibility, comprehensiveness of benefits, reimbursement formulas, entitlement, and level of government. The paper concludes by predicting that as transplant procedures become less constrained by organ supply and more routinely performed, they will lose the privileged political position that they now enjoy and will instead be obliged to compete for scarce governmental resources with other social goods on more equal terms. Government policy should be designed to encourage this competition.
The Economics and Ethics of Markets for Human Organs
Authors: Hansmann Henry
Published: January 2008

In 1984, federal legislation outlawing payment for human organs for transplantation was adopted after only cursory discussion of the underlying policy issues. More considered analysis suggests that this prohibition may be overly broad. It appears possible to design suitably regulated market-type approaches to the acquisition and allocation of cadaveric organs (and perhaps of organs from living donors as well) that will be neither unduly offensive to ethical sensibilities nor easily abused and that may yield significant improvements over the existing system of organ procurement, which presents important ethical and practical problems of its own. Moreover, whatever ultimate judgment we reach concerning the merits of markets for transplantable organs, analysis of the sources of the initial moral resistance to the commercialization that lies behind measures such as the 1984 legislation offers insights into the respective roles of market and nonmarket institutions in general.
Ethical Criteria for Procuring and Distributing Organs for Transplantation
Authors: Childress James F.
Published: January 2008

This article provides an ethical analysis and assessment of various actual and proposed policies of organ procurement and distribution in light of moral principles already embedded in U.S. institutions, laws, policies, and practices. Evaluating different methods of acquisition of human body parts–donation (express and presumed), sales, abandonment, and expropriation–the author argues for laws and policies, including required request, to maintain and facilitate express donation of organs by individuals and their families. Such laws and policies need adequate time for a determination of their effectiveness before society moves to other major alternatives, such as a market. In organ allocation and distribution, which have close moral connections with organ procurement, the author defends the judgment of the federal Task Force on Organ Transplantation that the community should have dispositional authority over donated organs, that professionals should be viewed as trustees and stewards of donated organs, and that the public should be heavily involved in the formation of policies of allocation and distribution. Concentrating on policies being developed in the United Network for Organ Sharing, the author examines the point system for cadaveric kidneys, the access of foreign nationals to organs donated in the U.S., and the multiple listings of patients seeking transplants. He concludes by identifying two major problems of equitable access to donated organs that will have to be addressed by social institutions other than UNOS: access to the waiting list for donated organs and the role of ability to pay in extrarenal transplants.
The Florida Health Care Access Act: A Blended Regulatory/Competitive Approach to the Indigent Health Care Problem
Authors: Jones Katherine R.
Published: January 2008

The problem of indigent health care has received much attention from governmental officials, health care providers, health policy analysts, and others. A majority of states have generated legislative proposals to deal with the problem, although their strategies differ in terms of method and scope. This article discusses Florida's approach to the problem as contained in the Health Care Access Act of 1984 and subsequent legislation. The article will provide background on the reasons a hospital assessment strategy was chosen as the funding mechanism and will examine the problems that occurred during the implementation phase of the legislation.
Hospital and Patient Characteristics of Uncompensated Hospital Care: Policy Implications
Authors: Saywell Robert M. , Zollinger Terrell W. , Chu David K. W. , MacBeth Charlotte A. , Sechrist Mark E.
Published: January 2008

For this study, a sample of 1,689 patients classified as “charity” and “bad debt” cases in 1986 were identified from 27 general acute care hospitals and one tertiary hospital in Indiana. Half of the hospitals were in rural areas and 57 percent were small (less than 150 beds). Most of the patients (87.2 percent) incurred uncompensated amounts under $2,500, and 40 percent of the cases were below $500. About 72 percent of the patients with uncompensated care were from the same county as the location of the hospital (range from 30.9% to 100.0%). The majority of the cases (79.4 percent) with over $5,000 in uncompensated care were treated in urban hospitals. The average age of these patients was 27.2 years. Fifty-four percent of the patients were single, 60.7 percent were female, and nearly all (83.0 percent) were discharged to home care. Only 44.6 percent of the patients with uncompensated care had no insurance; 46.8 percent had some form of commercial insurance which covered part of the charges for care. The most common diagnosis for these patients was pregnancy and childbirth (22.8 percent), with injury and poisoning second (10.7 percent). The cases with $5,000 or more in bad debt (about 4 percent of the cases) account for 28.3 percent of the total uncollected amount. Bad debt represents a cost of doing business. Any national effort to contain health care costs must address this problem.
Public Sector Primary Care and Medicaid: Trading Accessibility for Mainstreaming
Authors: Fossett James W. , Peterson John A. , Ring Mary C.
Published: January 2008

Facilities operated by public and nonprofit agencies have become increasingly important sources of primary care for Medicaid patients. These facilities are particularly important sources of care in segregated, competitive urban areas, where they are more geographically accessible than many private physicians and expand the availability of care to Medicaid patients rather than substituting for care provided by private physicians. In rural areas, in contrast, the availability of care from public facilities appears to reduce the level of care Medicaid patients receive from private physicians in the counties where these facilities are located. These findings suggest that policymakers can expand urban Medicaid patients' access to care by spending on public care, but at the cost of increasing the segregation of Medicaid patients into a two-tier system of care.
The Potential Impact of Private Long-Term Care Financing Options on Medicaid: The Next Thirty Years
Authors: Wiener Joshua M. , Rubin Rose M.
Published: January 2008

This study analyzes the potential effect on the Medicaid program of private sector financing mechanisms for long-term care. The data are from the Brookings-ICF Long-Term Care Financing Model and include projections over the next thirty years. While private financing alternatives have some modest impacts on Medicaid expenditures and the number of Medicaid long-term care recipients, the data suggest relatively little change in the need for Medicaid. There will be substantial increases in Medicaid long-term care expenditures over time, and private sector options cannot change this much.
Ppos: The Employer Perspective
Authors: Rice Thomas , Gabel Jon , de Lissovoy Gregory
Published: January 2008

This paper reports the results of a national survey on employer experiences with preferred provider organizations (PPOs). The survey, conducted in 1987, included information from almost 700 telephone interviews with employee benefit managers. We found that 11 percent of employees are in PPOs. PPOs now have a strong presence among employers of all sizes. However, whereas they are a major force in the West, where almost one-third of employees are members, they have garnered only a 1 percent market share in the East. We examine the impact of PPOs on health insurance premiums and on employer satisfaction. The results show that in 1987, the year of the survey, PPOs appeared to provide mild cost savings compared to conventional insurance, and that employers were very satisfied with almost all aspects of PPOs, whereas they were surprisingly critical of their HMOs.
Hospital Mergers and Antitrust: An Economic Analysis
Authors: Blackstone Erwin A. , Fuhr Joseph P.
Published: January 2008

The hospital industry has recently experienced substantial merger activity. This paper examines several actual and proposed hospital mergers to determine the extent of competition in the affected markets and the effect these mergers may have on competition. Our focus is on mergers between hospitals in the same market. We define the relevant product and geographic market for hospitals, then develop criteria for evaluating hospital mergers and analyze several merger cases using these criteria. We conclude that these mergers threaten the competition that exists in most of the markets discussed, and that the claimed efficiency justification for mergers is not convincing.
The Prospects for Prepaid Long-Term Care: The Arizona Medicaid Experiment
Authors: Williams Frank G. , Phoenix David , Kirkman-Liff Bradford L.
Published: January 2008

Arizona is adding long-term care to its prepaid, capitated alternative to Medicaid. This article discusses the potential for this major cost-control experiment. Experience suggests that those able to qualify for long-term care will fare better than the poor did in the previous system. However, limiting eligibility will be the primary means of controlling costs; significant price competition is not likely to develop. The bidding process will serve more to transfer risk to contract providers than to improve program efficiency. Potential cost savings will be more than offset by an increased identification of need.
Financial Consequences of Joining a Medicare Hmo: An Application of the Illness Episode Approach to Estimating Out-of-Pocket Costs
Authors: Sofaer Shoshanna , Kenney Erin
Published: January 2008

To reduce Medicare costs, Medicare beneficiaries are being encouraged to enroll in “risk contract” HMOs. This paper explores the financial consequences to the elderly of joining a Medicare risk HMO. Using a new method for estimating consumer financial vulnerability called the illness episode approach, we modeled the out-of-pocket costs associated with thirteen illnesses of varying severity for beneficiaries with traditional Medicare coverage only and for beneficiaries who join one of two Los Angeles HMOs which charge no additional premium. The typical total charges for a year's treatment of these thirteen illnesses in Los Angeles in 1986 ranged from a low of $856 for moderate hypertension to a high of $28,411 for care of a severe stroke. For beneficiaries with traditional Medicare whose providers did not accept assignment, out-of-pocket costs ranged from $539 to $14,676 and from a low of 7.7 percent to a high of 84.1 percent of total charges. Out-of-pocket costs are considerably reduced in the two Medicare HMOs in this high-cost market; beneficiaries had modeled out-of-pocket costs ranging from $11 to $7,478 and from less than 0.1 percent of total charges to 60 percent of charges. Reductions in financial vulnerability ranged from over 20 percent to 99.3 percent. The relation of these reductions to altered benefit structures and the policy implications of the results are discussed.
No-Fault Cerebral Palsy Insurance: An Alternative to the Obstetrical Malpractice Lottery
Authors: Freeman Andrew D. , Freeman John M.
Published: January 2008

Sixty percent of malpractice premiums paid by obstetricians go to cover suits for alleged birth-related cerebral palsy (CP). Yet substantially less than half of that money goes to CP victims, and less than 10 percent of children with CP receive any compensation at all from tort suits. This paper proposes a system that would compensate all children born with CP for most handicap-related expenses, in exchange for which the children would be foreclosed from bringing suits alleging birth-related malpractice. Malpractice would be policed by a state board, which would investigate all CP cases. This proposal would be more equitable than current systems. It would also be less expensive, since it would avoid costly litigation and decrease the cost of obstetrical malpractice insurance.
Hospital Policy in the Netherlands: The Parameters of Structural Stalemate
Authors: Saltman Richard B. , Roo Adrian A. de
Published: January 2008

The Dutch hospital sector has recently been the subject of two divergent national policy initiatives. Following a mixed experience with regulation in the mid-1980s, the national government has now taken the first steps in a radical shift toward market-based competition. This article suggests that neither official strategy can address the fundamental structural and cultural factors that shape institutional behavior in the Dutch hospital system. Drawing upon empirical evidence from two 1987 hospital case studies, this article contends that Dutch hospital management reflects a precen-tralized insularity which, in turn, sharply reduces the likelihood that either publicly or privately framed decentralized strategies can be successfully implemented.
Promoting the Quality of Life in Nursing Homes: Can Regulation Succeed?
Authors: Nyman John A. , Geyer Cynthia R.
Published: January 2008

It has been assumed that the best policy for promoting quality of life in nursing homes is direct regulation. In this paper it is argued that if our experience in regulating quality of care is any indication, we may not possess the political will to successfully regulate quality of life. Moreover, from a legal perspective, the less concrete nature of the concept of quality of life may make it more difficult to regulate than quality of care. Finally, although regulation would probably be necessary if potential nursing home residents (and their agents) lacked the information or rationality to make choices that promoted their interests, this has never been shown to be the case empirically. Therefore, we may not be forced to choose regulation to achieve an adequate quality of life. Alternative–and perhaps better–policies may be available.
Retrenchment or Realignment? U.s. Mental Health Policy and Drgs
Authors: Ruggie Mary
Published: January 2008

The introduction of DRGs for financing health care is dramatically changing the system of delivery and provision in the U.S. To understand the consequences, it is important to focus not only on cost-containment issues but also on new institutional mechanisms fashioned to reshape health care delivery and provision. A realignment among the major actors is occurring, with the state adopting a central role in redefining its own function in the health care system, constructing a new framework and agenda for change, and enlisting the participation of other social actors in implementing change. The specific features of this realignment are analyzed in the context of mental health DRGs. This article concludes that, based on the consequences of DRGs to date, we ought to look beyond present indicators of retrenchment in the health care system to how the unique features of the American welfare state are continuing to evolve.
Political and Economic Determinants of Insurance Regulation in Mental Health
Authors: Lambert David A. , McGuire Thomas G.
Published: January 2008

This article studies determinants of two important sets of laws regulating insurance coverage for mental health care: mandated inclusion of minimum coverage for psychotherapy, and mandated coverage for psychologist services, the so-called freedom of choice (FOC) laws. Political market models are developed and estimated to examine the passage of mandates and FOC laws among all fifty states from 1968 through 1983. Findings indicate that a number of groups influence whether these laws are passed, including psychologists and the state, which acts both in its own interests as a direct provider of services and to protect the public's interest. A state's political system and socioeconomic environment also influence the likelihood of passage of these regulations. Our findings run counter to the assumption often made by policymakers and researchers that regulations exclusively serve the interests of providers.
Physician Payment and Cost-Containment Strategies in West Germany: Suggestions for Medicare Reform
Authors: Kirkman-Liff Bradford L.
Published: January 2008

The West German health care system pays ambulatory care physicians on a fee-for-service basis but employs a national relative value scale and regional capitation-based revenue pools to achieve expenditure controls on total physician reimbursement. Physician-controlled organizations manage these pools and conduct utilization reviews on their own members. The capitation rates are determined by negotiations between the physician associations and health insurers. The West German government has been able to exert some influence on the outcome of these negotiations through a quasi-governmental advisory body. Aspects of this structure could be adopted by Medicare in order to determine conversion factors for resource-based relative value scales or to create expenditure control and incentive structures for Medicare-participating physicians.
Child Health Policy in the U.s.: The Paradox of Consensus
Authors: Sardell Alice
Published: January 2008

The U.S. spends more of its total GNP on health services than any other nation, yet it has one of the highest infant mortality rates in the industrialized world. Young American children are immunized at rates that are one-half those of Western Europe, Canada, and Israel. In the mid-1980s, a consensus among policymakers on the need for federal action to improve child health services resulted in the expansion of Medicaid eligibility for pregnant women and young children and the separation of Medicaid eligibility from eligibility for AFDC. The current phase of child health policymaking includes discussion of much broader proposals for changes in health care financing and innovation in health care delivery. This examination of child health policy begins by reviewing the politics of maternal and child health services from the early twentieth century to the Reagan administration, including the role of feminist movements, the development of pediatrics, and the expansion of federal involvement during the 1960s. Next, the politics of Medicaid expansion as a strategy for addressing child health issues are discussed. Current critiques of child health services in the U.S. are examined, along with proposals to restructure health care financing and delivery. Central to the politics of child health policy during the 1980s and into the 1990s is the way in which child health has been defined. Infant mortality and childhood illness are presented as preventable problems. Investment in young children is discussed as a prudent as well as a compassionate policy, one which will reduce future health care costs and enhance our position in the international economy. Unlike other “disadvantaged groups,” children are universally viewed as innocent and deserving of societal support. Framing child health issues in these terms helped to produce consensus on the expansion of Medicaid eligibility. Yet the issues beyond the expansion of Medicaid eligibility involve the restructuring of health care financing and delivery, and, on these issues, conflict is far more likely than consensus.
Domestic Food Policy in the United States
Authors: Lipsky Michael , Thibodeau Marc A.
Published: January 2008

In this paper we review the major outlines of domestic food programs, assess their adequacy, and recommend ways to improve the relationship between food programs and hunger relief. In the Food Stamp Program we treat problems of outreach, coverage and the adequacy of benefits, and rationing access through imposition of costs on recipients. For WIC and commodity distribution programs we also discuss problems associated with the fragmentation of authority and dependence on nonprofit distributors.
Chronic Disease and Disadvantage: The New Politics of HIV Infection
Authors: Fox Daniel M.
Published: January 2008

HIV infection is now perceived as the end stage of a chronic disease that is spreading most rapidly among blacks and Hispanics. The politics of the HIV epidemic in the 1980s were dominated by four interacting factors: fear and fascination; who had the disease and to whom it seemed to be spreading; the endemic problems of United States social policy; and the impact on policy of advances in scientific knowledge. This paper analyzes the political history of each of these factors and describes the dominant policies of the federal government and the states regarding HIV in the areas of surveillance, prevention, research, and financing. Four uncertainties will have a profound influence on the future politics of the HIV epidemic: how the states and the federal government will address the general problems of paying for the care of people with chronic diseases and providing access to care for the uninsured and the underinsured; the number and distribution of the sexual behaviors that transmit infection with HIV and the effectiveness of policies to persuade people to modify these behaviors; precisely who uses addictive drugs and the effectiveness of measures to change their behavior; and the natural history of the virus.