Search

Hospitals are concerned about the implications of an increase in the number of uninsured people. Using data from the 1999 Medical Expenditure Panel Survey (MEPS), we calculate what percentage of hospital inpatient, emergency department, and outpatient visits are accounted for by uninsured people and predict how those shares would change under three different scenarios. We find that although the burden of the uninsured would remain a severe problem for some hospitals, it would not likely increase much for most of them. This finding reflects the relatively low utilization rates among those most likely to lose coverage: nonelderly, nonpregnant, and nondisabled workers and their families. [ABSTRACT FROM AUTHOR]

Faced with growing numbers of uninsured people, many communities are developing local programs to provide coverage or improve access. Some might predict that only those with health problems would participate; however, little is known about who enrolls. This paper examines participation and retention in three different community programs aimed at low-income uninsured adults. In two of the three programs, the typical participant had no health problems. Improved access to preventive and routine physician care, and increased security about getting access to care should the need arise, appeared to be the primary benefits of both initial and continued enrollment. [ABSTRACT FROM AUTHOR]

Although interest in expanding SCHIP coverage to parents has grown over the past five years, few such expansions have actually been implemented. State governments and health plan administrators remain concerned that these expansions will attract only high-risk enrollees, resulting in costly premiums that require large subsidies. We examine characteristics of enrollees in an SCHIP-like expansion program in Alameda County, California. According to our survey data, the program did not experience unfavorable selection. Rather, it attracted a broad range of eligible adults. Enrollees were comparable to the overall low-income population in Alameda County in terms of age, health status, and various utilization measures. [ABSTRACT FROM AUTHOR]

Objective: Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings., Methods: Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool., Results: In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year., Discussion: Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if recent growth in hospital and physician electronic health record (EHR) adoption and use is correlated with decreases in expenditures for elderly Medicare beneficiaries., Data Sources: American Hospital Association (AHA) General Survey and Information Technology Supplement, Health Information Management Systems Society (HIMSS) Analytics survey, SK&A Information Services, and the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013., Study Design: Fixed effects model comparing associations between hospital referral region (HRR) level measures of hospital and physician EHR penetration and annual Medicare expenditures for beneficiaries with one of four chronic conditions. Calculated hospital penetration rates as the percentage of Medicare discharges from hospitals that satisfied criteria analogous to Meaningful Use (MU) Stage 1 requirements and physician rates as the percentage of physicians using ambulatory care EHRs., Principal Findings: An increase in the hospital penetration rate was associated with a small but statistically significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary. An increase in physician EHR penetration was also associated with a significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary as well as a decrease in Medicare Part B expenditures per beneficiary. For the study population, we estimate approximately $3.8 billion in savings related to hospital and physician EHR adoption during 2010-2013. We also found that an increase in physician EHR penetration was associated with an increase in lab test expenses., Conclusions: Health care markets that had steeper increases in EHR penetration during 2010-2013 also had steeper decreases in total Medicare and acute care expenditures per beneficiary. Markets with greater increases in physician EHR had greater declines in Medicare Part B expenditures per beneficiary., (© Health Research and Educational Trust.)

Objective: To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010-2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care-sensitive conditions (ACSCs)., Data Sources: SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013., Study Design: Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30-day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings., Principal Findings: Each percentage point increase in market-level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level., Conclusions: This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions., (© Health Research and Educational Trust.)

Background: The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which includes the Meaningful Use (MU) incentive program, was designed to increase the adoption of health information technology (IT) by physicians and hospitals. Policymakers hope that increased use of health IT to exchange health information will in turn enhance the quality and efficiency of health care delivery. In this study, we analyze the extent to which key outcomes vary based on the levels of health ITness among physicians and hospitals before the HITECH and MU programs led to increases in adoption and changes in use. Our findings provide an important baseline for a future evaluation of the impact of these programs on population-level outcomes., Methods: We constructed measures of the degree of hospital and physician adoption and use ("health ITness") at the level of the hospital referral region (HRR). We used data from the 2010 IT Supplement of the American Hospital Association (AHA) Annual Survey of Hospitals to capture hospital health ITness and data from the 2010 survey of ambulatory health care sites produced by SK&A Information Services for the physician measure. We conducted cross-sectional analyses of the relationship between market-level Medicare costs and use and three measures: (1) physician health ITness, (2) hospital health ITness, and (3) an overall measure of health ITness., Results: In general, greater levels of physician health ITness are associated with decreasing costs and use. Many of these relationships lose statistical significance, however, when we control for population and market characteristics such as the average age and health status of Medicare beneficiaries, mean household income, and the HMO penetration rate. Several of the relationships also change according to the level of hospital health ITness., Conclusions: Our findings suggest that greater levels of physician health ITness are associated with decreasing costs and use for a number of services, including inpatient costs and stays, imaging services, and lab tests, in 2010. Our health ITness and outcomes measures are aggregated at the HRR level; as such, these results do not suggest that the adoption and use of health IT by individual physicians or hospitals leads to decreases in costs or use for their individual patients. Nevertheless, these baseline findings provide important information to be considered in future research analyzing the impact of HITECH and the MU incentives., (Copyright © 2014. Published by Elsevier Inc.)

In enacting the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act, Congress set ambitious goals for the nation to integrate information technology into health care delivery. The provisions called for the electronic exchange of health information and the adoption and meaningful use of health information technology in health care practices and hospitals. We examined the marketplace and regulatory forces that influence HITECH's success and identify outstanding challenges, some beyond the provisions' control. To reach HITECH's goals, providers and patients must be persuaded of the value of health information exchange and support its implementation. Privacy concerns and remaining technical challenges must also be overcome. Achieving HITECH's goals will require well-aligned incentives, both visionary and practical pursuit of exchange infrastructure, and realistic assumptions about how quickly such wholesale change can be accomplished. The use of metrics to show adoption proceeding at a reasonable pace, increased flow of data across parties, and evidence that care is improving, at least in areas with robust systems, will be essential to persuade stakeholders that the initiative is progressing well and warrants continued investment.

Objective: To identify prevalences and predictors of nonfinancial barriers that lead to unmet need or delayed care among U.S. adults., Data Source: 2007 Health Tracking Household Survey., Study Design: Reasons for unmet need or delayed care in the previous 12 months were assigned to one of five dimensions in the Penchansky and Thomas model of access to care. Prevalences of barriers in each nonfinancial dimension were estimated for all adults and for adults with affordability barriers. Multivariable logistic regression models were used to estimate associations between individual, household, and insurance characteristics and barriers in each access dimension., Principal Findings: Eighteen percent of U.S. adults experienced affordability barriers and 21 percent experienced nonfinancial barriers that led to unmet need or delayed care. Two-thirds of adults with affordability barriers also reported nonfinancial barriers. Young adults, women, individuals with lower incomes, parents, and persons with at least one chronic illness had higher adjusted prevalences of nonfinancial barriers., Conclusions: Nonfinancial barriers are common reasons for unmet need or delayed care among U.S. adults and frequently coincide with affordability barriers. Failure to address nonfinancial barriers may limit the impact of policies that seek to expand access by improving the affordability of health care., (© Health Research and Educational Trust.)

Chronic obstructive pulmonary disease (COPD), diabetes and asthma are chronic illnesses that affect a substantial number of people. The continued high cost of clinic- and hospital-based care provision in these areas could be reduced by patients self-monitoring their condition more effectively. Such a move requires an understanding of how to predict self-monitoring compliance. Ajzen's theory of planned behaviour (TPB) makes it possible to predict those clients who will comply with medical guidelines, prescription drug intake and self-monitoring behaviours (peak flow or blood sugar levels). Ninety-seven clients attending a medical centre located in a large urbanised area of Northern Ireland completed TPB questionnaires. Significant amounts of variance explained by the TPB model indicated its usefulness as a predictor of self-monitoring behaviour intentions in the sample. The results also highlighted the importance of subjective norm and perceived behavioural control within the TPB in predicting intentions. The utility of the TPB in this study also provides evidence for health promotion professionals that costly clinic/hospital treatment provision can be reduced, whilst also being satisfied with ongoing client self-monitoring of their condition.

Objective: To examine the extent to which health plan quality measures capture physician practice patterns rather than plan characteristics., Data Source: We gathered and merged secondary data from the following four sources: a private firm that collected information on individual physicians and their health plan affiliations, The National Committee for Quality Assurance, InterStudy, and the Dartmouth Atlas., Study Design: We constructed two measures of physician network overlap for all health plans in our sample and linked them to selected measures of plan performance. Two linear regression models were estimated to assess the relationship between the measures of physician network overlap and the plan performance measures., Principal Findings: The results indicate that in the presence of a higher degree of provider network overlap, plan performance measures tend to converge to a lower level of quality., Conclusions: Standard health plan performance measures reflect physician practice patterns rather than plans' effort to improve quality. This implies that more provider-oriented measurement, such as would be possible with accountable care organizations or medical homes, may facilitate patient decision making and provide further incentives to improve performance.

Most proposals to improve access for uninsured adults focus on removing financial barriers to health care. Health services researchers have long recognized, however, that access to care is a multidimensional concept consisting of both financial and nonfinancial dimensions. While financial barriers faced by those without health insurance have been well-documented, it is not known to what degree nonfinancial barriers limit access for those without coverage. In this study we sought to identify the types and frequencies of nonfinancial access barriers faced by low-income uninsured adults, as well as determine how frequently nonfinancial barriers coexist with financial access barriers in this population. We conducted a telephone survey of 1,118 low-income uninsured adults in Alameda, California, Austin, Texas, and Southern Maine who had enrolled in local access programs funded through the Robert Wood Johnson Foundation's Communities in Charge initiative. Financial barriers were the most often cited barrier to access in each of the three groups, though nonfinancial barriers were often cited as well. Across all three populations, one-third to one-half of respondents with financial access barriers also cited one or more nonfinancial barriers as contributing to their problems accessing health care. Our results suggest that many uninsured adults face nonfinancial health care barriers in addition to their well-documented financial challenges. Health reform efforts must address both types of barriers in order to maximally improve access for the uninsured population.

Purpose: The purpose of this study is to estimate the own- and cross-price elasticity of brand-name outpatient prescription drug cost-sharing for maintenance medications and to estimate the effects of changes in the price differential between generic and brand-name prescription drugs., Methodology/approach: We first review the literature on the effects of an increase in brand-name drug patient cost-sharing. In addition, we analyze two examples of utilization patterns in filling behavior associated with an increase in brand-name cost-sharing for patients in employer-sponsored health plans with chronic illness., Findings: We found that the own-price elasticity of demand for brand-name prescription drugs was inelastic. However, the cross-price elasticity was not consistent in sign, and utilization patterns for generic prescription fills did not always increase after a rise in brand-name cost-sharing., Research Limitations: The empirical examples are limited to the experience of patients with employer-sponsored health insurance., Practical Implications: The common practice of increasing brand-name prescription drug patient cost-sharing to increase consumption of generic drugs may not always result in higher generic medication use. Higher brand-name drug cost-sharing levels may result in discontinuation of chronic therapies, instead of therapeutic switching., Originality/value of Chapter: The value of this chapter is its singular focus on the effects of higher brand-name drug cost-sharing through a synthesis of the literature examining the own- and cross-price elasticity of demand for brand-name medications and two empirical examples of the effects of changes in brand-name cost-sharing.

This study estimates the effects of an increase in an outpatient prescription drug copayment using a natural experiment based upon a large firm that implemented such an increase. The findings suggest that the primary effect of a copayment increase is attenuation of the trend in prescription drug utilization. We also find an initial reduction in expenditures, with the effects on spending diminishing. Employees with an existing chronic illness and those without a chronic illness show a similar, inelastic response to a copayment increase; employees with a newly diagnosed chronic illness have a more inelastic response.

In the absence of broad federal health care reform, interest has grown in local solutions to the problem of providing health care to the uninsured. Community-based donated medical care models have emerged as one alternative. We examine the early experience of a donated care program in southern Maine called CarePartners. Although such programs are often viewed as a short-term solution for those temporarily without health insurance, we find that CarePartners served a different role for many individuals. While clearly a stopgap measure for some enrollees, CarePartners appears to be a longer-term means for getting access to care for most enrollees.

Health maintenance organizations' (HMOs') restrictions on the size of their physician networks may facilitate cost containment and quality improvement activities but may also impede access to care and impose barriers to those wishing to switch health plans or jobs. We examine the extent, variation, and predictors of overlap in HMO physician networks. We predict that people who switch HMOs have a reasonable likelihood (50 percent) of being able to retain their physician. Overlap ranges from an upper quartile of 69 percent to a lower quartile of 34 percent. Group/staff-model HMOs have little overlap, while younger plans, for-profit plans, and plans in small markets have greater overlap.

Objective: Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans., Data Sources: The analysis is based on a sample of Medicare beneficiaries drawn from the 1996-1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration)., Study Design: Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums., Principal Findings: We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points., Conclusions: This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.

This article summarizes the research and data currently available on different dimensions of consumer choice. These dimensions include not only whether to participate in a health care plan and which plan to select if given a choice but also the decisions that lead to having a choice and the implications of making the choice. Data are presented on what choices consumers face, how many are given what kinds of choices, what constraints they face, what we know about how they make these choices, and what information they are given and what they use. The majority of Americans are offered some kind of health insurance plan either through their place of employment or as a dependent on someone else's employer-sponsored health plan. About half of those offered health insurance are offered a choice, usually of only two or three plans. The majority elect to participate in one of those plans.

Objective: To assess the degree to which premium reductions will increase the participation in employer-sponsored health plans by low-income workers who are employed in small businesses., Data Sources/study Setting: Sample of workers in small business (25 or fewer employees) in seven metropolitan areas. The data were gathered as part of the Small Business Benefits Survey, a telephone survey of small business conducted between October 1992 and February 1993., Study Design: Probit regressions were used to estimate the demand for health insurance coverage by low-income workers. Predictions based on these findings were made to assess the extent to which premium reductions might increase coverage rates., Data Collection/extraction Methods: Workers included in the sample were selected, at random, from a randomly generated set of firms drawn from Dun and Bradstreet's DMI (Dun's Market Inclusion). The response rate was 81 percent., Findings: Participation in employer-sponsored plans is high when coverage is offered. However, even when coverage is offered to employees who have no other source of insurance, participation is not universal. Although premium reductions will increase participation in employer-sponsored plans, even large subsidies will not induce all workers to participate in employer-sponsored plans. For workers eligible to participate, subsidies as high as 75 percent of premiums are estimated to increase participation rates from 89.0 percent to 92.6 percent. For workers in firms that do not sponsor plans, similar subsidies are projected to achieve only modest increases in coverage above that which would be observed if the workers had access to plans at unsubsidized, group market rates., Conclusions: Policies that rely on voluntary purchase of coverage to reduce the number of uninsured will have only modest success.

To meet its goal of universal health insurance coverage, the Clinton health plan requires all employers to offer health insurance to their employees. Using survey data on more than 2,200 small businesses, we estimate how many firms and employees would be affected by this mandate and calculate the financial burden, adjusting for the small-business subsidies recommended in the Clinton plan. Because of the payroll caps, almost 60 percent of small businesses that now offer insurance will experience a reduction in premiums. The average reduction is approximately $1,500 per full-time equivalent (FTE) per year. The majority of firms that offer insurance and face an increase in liability under the Clinton plan will incur an increase of less than $1,000 per FTE per year. Firms that do not now offer insurance will incur, on average, a liability of $500 to $900 per FTE.

Over the past 10 years there have been dramatic changes in health care financing in the United States, such as Medicare's Prospective Payment System for hospitalized Medicare beneficiaries, and in health services delivery, such as the growth in health maintenance organizations and other forms of managed care. These changes have occurred largely in response to payors' concerns about the rising cost of health care. A study of such changes in financing and delivery, and how specific groups of patients are affected is necessary so that the effects of these changes on patients' health can be determined. We examined the hospitalization rates for patients with musculoskeletal diseases in Michigan from 1980 through 1987. During this period, the overall age-adjusted hospitalization rates decreased 7.0% per year (p = 0.001). The decrease occurred less for surgical discharges (6.0% per year) than for medical discharges (8.6% per year) (p < 0.001). While these overall trends are of interest, they obscure disease-specific trends that vary significantly from both the overall, and the medical and surgical trends. For example, while surgical discharges, in general declined, procedures related to major joint and limb reattachment (DRG #209) increased at a rate of 6.3% per year. And while medical discharges in general decreased over this period, discharges for osteomyelitis increased 5.4% per year. The patterns of disease-specific trends offers insight into the possible causes for these changes. Finally, it is important to understand the epidemiology of hospital use to evaluate the effects of new medical care delivery and payment systems on the care of subsets of patients.

Background: Health professionals have charged that magazines that depend on revenues from cigarette advertising are less likely to publish articles on the dangers of smoking for fear of offending cigarette manufacturers. Special concern has focused on magazines directed to women. Restricted coverage of smoking hazards could lead readers to underestimate the risks of smoking in relation to other health risks., Methods: Using logistic-regression analysis of a sample of 99 U.S. magazines published during 25 years (1959 through 1969 and 1973 through 1986), we analyzed the probability that the magazines would publish articles on the risks of smoking in relation to whether they carried advertisements for cigarettes and in relation to the proportion of their advertising revenues derived from cigarette advertisements. We controlled for other factors that might influence coverage., Results: The probability of publishing an article on the risks of smoking in a given year was 11.9 percent for magazines that did not carry cigarette advertisements, as compared with 8.3 percent for those that did publish such advertisements (adjusted odds ratio, 0.73; 95 percent confidence interval, 0.42 to 1.30). For women's magazines alone, the probabilities were 11.7 percent and 5.0 percent, respectively (adjusted odds ratio, 0.13; 95 percent confidence interval, 0.02 to 0.69). When the proportion of revenues derived from cigarette advertising was the independent variable, the probability of publishing an article on the risks of smoking in a given year was reduced by 38 percent (95 percent confidence interval, 18 percent to 55 percent) for magazines with the average proportion of total advertising revenues derived from cigarette advertising for the entire sample of magazines (6 percent) as compared with magazines with no cigarette advertising. This relation was particularly strong in the case of women's magazines. An increase of 1 percent in the share of advertising revenue derived from cigarette advertisements decreased the probability of covering the risks of smoking by three times as much as in other magazines., Conclusions: This study provides strong statistical evidence that cigarette advertising in magazines is associated with diminished coverage of the hazards of smoking. This is particularly true for magazines directed to women.

We consider methods for selecting the joint specification of the mean and variance functions in statistical models for rates or counts. Based on analyses of diagnosis-specific hospital discharge rates in Michigan, we show that a Poisson model with an extra variance component for the systematic variation is superior to several other probability models with regard to specification of the error structure. Further, the deviance residual appears superior to the Pearson residual. The proper specification of such variation is crucial for many types of analyses, such as identification of outliers and regression analyses designed to explain the systematic component of the variation.

Purpose: The rise in health care costs has occasioned a number of initiatives in an attempt to reduce the rate of increase. Despite the growth of health maintenance organizations and preferred provider organizations and the introduction of Medicare's prospective payment system, health care costs have continued to increase. Coincident with these efforts, a number of researchers have shown that there exists wide variation in age-adjusted hospital discharge rates, which translate into significant variation in per capita expenditures. Much of the focus on the reasons for hospital admission variability has been on physician practice variation. If most of the variation in hospital discharge rates is due to physician practice style, then payment systems can be developed (e.g., capitation) that limit physician practice variation without harming patients. We examined socioeconomic factors in Michigan communities to assess their association with hospital discharge rates for patients with musculoskeletal diseases., Patients and Methods: Data on hospital discharges from 1980 and 1987 were taken from the Michigan Inpatient Data Base. All admissions from the major diagnostic category 8, diagnosis-related group (DRG) 209-256 were included. Zip code-specific hospitalization data were grouped into small geographic areas or hospital market communities (HMCs). Discharge rates were calculated, and profiles of the socioeconomic characteristics of each of the HMCs were developed. A Poisson regression model with an extrasystematic component of variance was used to analyze the association of HMC socioeconomic characteristics with age-adjusted hospital use., Results: We found that four socioeconomic variables, average annual income per capita, percent of the population with four years of college, percent of the population living in an urban area, and percent of families with incomes below the poverty line, explained 26.6% (R2) of the variation in overall hospital discharge rates (p less than 0.001). Moreover, we found that the ability of the model to explain variability was influenced by the type of disease, and that these socioeconomic variables had a consistent effect across the range of DRGs. Finally, we noted that, over the period of 1980 to 1987, socioeconomic factors remained important in explaining hospital use despite the dramatic changes in the delivery of care over this period., Conclusion: Socioeconomic factors play a significant role in explaining the observed variation in hospital discharge rates for musculoskeletal diseases. Models utilizing only physician practice variation to account for the population-based differences in discharge rates are overly simplistic. In order to ensure that vulnerable subsets of the population are not harmed by the introduction of cost-containment strategies based on simplistic models, more attention must be paid to the socioeconomic and epidemiologic factors related to hospital use.

Capitation plans may place their enrollees at risk of rationed services if they do not adjust for underlying patient characteristics that dictate differing levels of care. To assess the degree to which population-based socioeconomic characteristics are associated with hospital use, this study explored small-area variation in hospital discharges for gastrointestinal and liver (GI) Diagnosis Related Groups (DRGs). Utilizing a 1980 Michigan database of 1.5 million discharges, we constructed age-adjusted, population-based discharge rates for the GI DRGs. We then evaluated the effect of poverty, defined by the percent of households in a hospital market community below the poverty line. Using regression techniques, we found that poverty explained 27.5% of the variation in GI hospital discharges, with the poor admitted more often (p less than 0.0001). Using cost weighted discharge rates as the dependent variable, we found that poverty explained 20.3% (p = 0.0003) of the variation in cost weighted discharges. These results suggest that poverty explains a significant amount of variation in hospital discharges and has a significant effect on associated small-area hospitalization costs in GI diseases. Practicing gastroenterologists and surgeons need to be aware of factors that influence patients utilizing their services in order to retain their role as patient advocates as changes in payment systems are suggested.

Hospital discharge rates vary substantially among 60 communities in Michigan. (R2 = 90 percent and R2 = 85 percent of the systematic variance is explained by community effects for nonsurgical and surgical discharges, respectively.) The ranking of communities by discharge rates is stable over a five-year period (Spearman rho = 0.78 for nonsurgical discharges and 0.72 for surgical discharges). Surgical discharge rates decreased substantially (4 percent per year) over this time period, while nonsurgical rates showed no consistent pattern. Communities with exceptional discharge rates showed no substantial or significant regression toward the mean through the five-year study.

A principal problem with previous studies that have estimated the effects of prepaid group practices (PGPs) on hospital costs and use is the treatment of PGP growth rates as an exogenous variable. To the extent that the entry and subsequent growth of PGPs may be affected by high hospital costs and low use, the observed association between hospital costs and use and PGP market shares is confounded. To separate the effects of PGP growth on hospital expenses and use from the effects of hospital expenses and use on PGP growth, a simultaneous-equation model is estimated using data for 25 standard metropolitan statistical areas (SMSAs) from 1972 to 1982. The results indicate that PGP growth has a significant positive effect on average hospital expenses per day and per admission in an SMSA, but no statistically significant effect on average hospital expenses per capita. PGP growth also has a significant negative effect on both admission rates and average length of stay. In contrast to results from single-equation specifications, neither higher hospital expenses per day nor per admission are found to result in higher levels of PGP market shares in an SMSA and, in fact, both lower hospital expenses per capita and lower admission rates lead to significantly higher PGP market share levels.

Although numerous studies have been made of the determinants of small-area variation in hospital discharge rates, there is still disagreement about the role of socioeconomic factors. The lack of consensus stems, in part, from the difficulty in comparing results across studies that use different units and methods of analysis. Many of the studies using well-defined hospital service areas did not have the data needed to conduct a controlled analysis of the determinants of hospital utilization. Most of the studies that have performed controlled analyses have relied on larger geopolitical areas, which are not believed to capture self-contained health care systems. The study described here used a consistent set of data, three methods of analysis, and two units of analysis to test the importance of socioeconomic characteristics in explaining the variation in medical and surgical discharge rates in Michigan. Socioeconomic factors are found to be statistically significant determinants of the variation in both medical and surgical discharge rates, whether the method of analysis is simple correlations or multiple regressions, and whether the unit of analysis is the county or a well-designed hospital service area. These results suggest that previous small-area variation studies may have incorrectly concluded that socioeconomic characteristics do not explain differences in utilization rates.

Health care coalitions are an important element in the 1980s' emphasis on private sector cost-containment initiatives. The peak years for the formation of these coalitions were 1982 and 1983. Based on a 1986 telephone survey of 215 health care coalitions, we provide an analysis of the maturing health care coalition movement, focusing on who is in them, what they do, how they are doing, and what they have accomplished. We also propose two life-cycle models that describe most coalitions. One model fits the temporary, outcome-oriented employer-only coalitions, while the second fits the more process-oriented broad-based coalitions. Our data, along with more recent information, suggest that at present the coalition movement is in decline.

There has been increasing attention paid to small area variation in hospital discharge rates. While there is general agreement about the importance of correcting for the migration of patients to hospitals outside their geographic area when constructing population-based hospital use rates for these small areas, there have been no studies of the sensitivity of simple correlations or multiple regression results to these adjustments. Given the paucity of patient origin data, which is needed to adjust hospital discharge rates for patient crossovers, the problems of measurement error present in the more readily available site-of-care data need to be addressed. This paper analyzes the variation in hospital discharge rates, both an unadjusted site-of-care rate and an adjusted patient origin rate, across the 68 counties in the lower peninsula of Michigan in 1980. The results indicate that both simple correlations and multiple regression results of these rates with socio-economic and health care resource characteristics of the counties are very sensitive to the specification of the discharge rate, with the analysis of the unadjusted rate potentially leading to incorrect policy recommendations. The explanatory power of the socio-economic characteristics is underestimated and that of health care resource measures most likely overestimated when the discharge rate is not adjusted for patient crossovers.

Data from the National Medical Care Utilization and Expenditure Survey of 1980 are used to examine the characteristics of high-volume users of health care services, contrasting them with low-volume users and those who used no services at all. The three major types of medical care services examined are hospital inpatient care, ambulatory visits, and prescribed medications. Low users were defined, respectively, as those who during the year had either one or two hospital days, one nondental visit to a physician or nonphysician, and one prescribed medicine acquisition. High users were those with, respectively, 17 or more hospital days, 20 or more visits, and 25 or more prescribed medicine acquisitions. A very small percent of the U.S. civilian noninstitutionalized population and of those who used services at all during the year consume a large percent of services in each of the three service types. High users of inpatient hospital care constitute 1.7 percent of the civilian noninstitutionalized population and 15 percent of persons hospitalized during the year, yet they used 54.4 percent of all hospital days used by the reference population. High users of ambulatory services constitute 4.5 percent of the reference population and only 5.7 percent of all users of ambulatory services, yet they accounted for 32.3 percent of all ambulatory visits. For prescribed medications, only 3.7 percent of the civilian noninstitutionalized population are high users, comprising 5.9 percent of all users, but they account for 32.9 percent of all prescription acquisitions. At the other extreme, low users of ambulatory care visits represent 17 percent of the reference population, and 21 percent of all users of such care, but only 3.3 percent of all visits. High users share certain characteristics. They are more likely than low users to be older and poorer, to have poorer health status and more medical conditions, and are more likely to have functional limitations. Both univariate and multivariable analyses show that the most important distinguishing characteristics of high users of any of the three medical services are poor health status, severe functional limitations, and the presence of multiple medical conditions--most importantly cancer, cardiac disorders, musculoskeletal diseases, respiratory diseases, and injuries and poisonings. Almost all high-volume users of every category of service (88 percent for hospital days, 89 percent for ambulatory visits, and 94 percent for prescribed medications) had at least three different diagnostic conditions reported during the year.(ABSTRACT TRUNCATED AT 400 WORDS)

Policymakers are interested in the effect health maintenance organizations (HMOs) have had not only on the hospital expenditures of their enrollees, but also on the expenditures of non-HMO consumers. Previous studies of the "HMO effect" have focused on the comparison between hospital expenditures of HMO enrollees and those of non-HMO groups within the same market area. To the extent that the expenditures of non-HMO groups are affected by the presence of HMOs, this comparison will not give an accurate measure of the change in expenditures due to HMOs for either group. Using SMSAs without any HMOs as the comparison group can provide an accurate measure of the HMO effect on overall hospital expenses, if any nonrandom selection process of HMOs into SMSAs is controlled. In this article, the effect of prepaid group practices (PGPs) on overall hospital expenses is estimated using a simultaneous-equation model and all 283 standard metropolitan statistical areas (SMSAs) in 1980, controlling for any nonrandom selection process. The results indicate that while a significant selectivity bias exists that must be corrected, there is no significant PGP effect on hospital expenses. Controlling for other factors, hospital expenses per capita, per admission, and per day do not change as the PGP market share increases. While hospital expenses per capita for PGP enrollees may be falling, those of non-PGP groups in those SMSAs must be increasing by offsetting amounts.

Although competition for consumers is increasing in the health care sector, there is disagreement about whether it is resulting in cost containment, as its supporters have argued it would. In part this stems from a confusion between price competition, which under ideal circumstances leads to the production of services at the lowest possible cost, and nonprice competition--or rivalry--which under many circumstances will lead to increased costs. In this paper, I examine the evidence about the competitive response to the growing presence of health maintenance organizations in the health care marketplace. The available evidence suggests that providers are responding not with classical cost-containing price competition but, instead, with cost-increasing rivalry, characterized by increased expenditures to promote actual or perceived product differentiation.

In 1917, the Bureau of Labor Statistics surveyed 11,946 white households nationwide, recording demographic variables and yearly expenses on physicians, medicines, nurses, and hospitals. There was significant variation in these medical expenses among the nine census bureau regions. Using a multivariate analysis, we demonstrated that some of the variation could be explained by household variables, such as household income and size, some of the variability could be explained by the availability of physicians and hospital beds, and some could be explained by interactions between the different types of health care. However, after accounting for these possible explanatory variables, significant regional variation remained. We conclude that regional variation in health care expenditures is not new, and that studying how regional variation has changed during the twentieth century is likely to help explain why that variation exists today.