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Objective: To evaluate whether adjusting the Health Plan Employer Data and Information Set (HEDIS) low birth weight (LBW) measure for maternal risk factors is feasible and improves its validity as a quality indicator., Data Source: The Washington State Birth Event Record Data for calendar years 1989 and 1990, including birth certificate data matched with mothers' and infants' hospital discharge records, with 5,837 records of singlet on infants identified as LBW (< 2,500 g) and a 25 percent sample ( n = 31,570) of the normal-weight births (

Objective: To simulate whether allowing small businesses to offer employer-funded medical savings accounts (MSAs) would change the amount or type of insurance coverage., Study Setting: Economic policy evaluation using a national probability sample of nonelderly non-institutionalized Americans from the 1993 Current Population Survey (CPS)., Study Design: We used a behavioral simulation model to predict the effect of MSAs on the insurance choices of employees of small businesses (and their families). The model predicts spending by each family in a FFS plan, an HMO plan, an MSA, and no insurance. These predictions allow us to compute community-rated premiums for each plan, but with firm-specific load fees. Within each firm, employees then evaluate each option, and the firm decides whether to offer insurance-and what type-based on these evaluations. If firms offer insurance, we consider two scenarios: (1) all workers elect coverage; and (2) workers can decline the coverage in return for a wage increase., Principal Findings: In the long run, under simulated conditions, tax-advantaged MSAs could attract 56 percent of all employees offered a plan by small businesses. However, the fraction of small-business employees offered insurance increases only from 41 percent to 43 percent when MSAs become an option. Many employees now signing up for a FFS plan would switch to MSAs if they were universally available., Conclusions: Our simulations suggest that MSAs will provide a limited impetus to businesses that do not currently cover insurance. However, MSAs could be desirable to workers in firms that already offer HMOs or standard FFS plans. As a result, expanding MSA availability could make it a major form of insurance for covered workers in small businesses. Overall welfare would increase slightly.

Objectives: (1) To describe the issues in developing a clinical predictor of cesarean delivery that could be used to adjust reported cesarean rates for case mix, and (2) to compare its performance to other, simpler predictors using clinical and statistical criteria., Data Sources: Singleton births greater than 2,500 grams in Washington State in 1989 and 1990 for whom mothers and infant hospital discharge records could be matched to birth certificate data., Design: Statistical analysis of retrospective merged hospital and birth certificate data, which were used to develop variables and models to predict the probability that any particular delivery would be a cesarean., Principal Findings: Merged data led to better predictor variables than those based on one source. A simple four-category hierarchical classification into births with prior cesarean, breech but no prior cesarean, first birth, and other explains 30 percent of the variance in individual cesarean rates. The full clinical model fit the data well and explained 37 percent of the variance. Multiparas without serious complications comprised 35 percent of the mothers and averaged less than 2 percent cesareans. A hospital's predicted cesarean rate depends strongly on the proportion of its births that are first births., Conclusion: Government and private agencies have reported cesarean rates as measures of hospital performance. Depending on data and resources available, both simple and complex measures of case mix can be used to adjust reported rates. These adjustments should not include all variables related to the rates. Proper adjustments may not alter hospital rankings greatly, but they will improve the validity and acceptability of the reports.

Consumers, payers, and policymakers are demanding to know more about the quality of the services they are purchasing or might purchase. The information provided, however, is often driven by data availability rather than by epidemiologic and clinical considerations. In this article, we present an approach for selecting topics for measuring technical quality of care, based on the expected impact on health of improved quality. This approach employs data or estimates on disease burden, efficacy of available treatments, and the current quality of care being provided. We use this model to select measures that could be used to measure the quality of care in health plans, but the proposed framework could also be used to select quality of care measures for other purposes or in other contexts (for example, to select measures for hospitals). Given the limited resources available for quality assessment and the policy consequences of better information on provider quality, priorities for assessment efforts should focus on those areas where better quality translates into improved health.

In a randomized trial of the effects of medical insurance on spending and the health status of the nonaged, we previously reported that patients with limited cost sharing had approximately one-third less use of medical services, similar general self-assessed health, and worse blood pressure, functional far vision, and dental health than those with free care. Of the 20 additional measures of physiological health studied here on 3,565 adults, people with cost sharing scored better on 12 measures and significantly worse only for functional near vision. People with cost sharing had less worry and pain from physiological conditions on 33 of 44 comparisons. There were no significant differences between plans in nine health practices, but those with cost sharing fared worse on three types of cancer screening and better on weight, exercise, and drinking. Overall, except for patients with hypertension or vision problems, the effects of cost sharing on health were minor.