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States have shown creativity and adaptability in developing outreach strategies to promote State Children's Health Insurance Program (SCHIP) enrollment. As the program has matured and the fiscal environment has tightened, States have learned what efforts are successful and have tailored their approaches accordingly. This article reviews the evolution of State outreach strategies under SCHIP, using qualitative information from all 50 States and the District of Columbia. Early campaigns were aimed at building broad awareness of SCHIP. Over time, States have adapted their outreach campaigns to close the gaps in enrolling hard-to-reach populations, by modifying their target populations, messages, methods, organizational strategies, and emphasis., INTRODUCTION Since the initiation of SCHIP in 1997, States have recognized the importance of outreach in raising awareness and facilitating enrollment in the program. States have shown creativity and adaptability [...]

This study explores how a health maintenance organization's (HMO) capacity and incentive's to manage care might be used to improve access. In the early 1990s, the Florida Healthy Kids (FHK) demonstration extended Medicaid-like HMO coverage to indigent children in the public schools of Volusia County, Florida. The study finds that uninsured student months in area public schools were likely reduced by one-half Utilization and cost levels for these indigent enrollees proved to be indistinguishable from commercial clients; and measures of access, utilization, and satisfaction for enrollees were in line with (and in some cases, superior to) non-enrollees with private insurance. Overall, these results suggest the value of using schools as a medium for providing coverage, and the importance of taking deliberate steps to manage access to reduce non-financial barriers to care., INTRODUCTION One concern about capitated managed care is that providers will act on narrow financial incentives and use their control over beneficiaries to limit access to costly care, such as [...]

This article examines the impact of expanding Medicare Part B coverage of mental health services, based on analysis of 6 years of Medicare Part B claims data (1987-92). Inflation-adjusted per capita spending more than doubled (from $9.91 to $21.63) following the elimination of the annual outpatient treatment limit and extension of direct reimbursement to clinical psychologists and social workers. There was a 73-percent increase in the user rate (from 23.25 to 40.20 per 1,000 Medicare beneficiaries), and a 27-percent increase in the average number of services per user (from 8.9 to 11.3). Mental health spending increased from 1 percent to 2 Percent of expenditures for Part B professional services. Ongoing monitoring of mental health utilization is desirable to ensure that recent access gains are not eroded with the increasing shift to managed care and implementation of gatekeeper mechanisms., INTRODUCTION Public and private health insurance programs traditionally have limited mental health benefits due to concerns about moral hazard(1) and adverse selection as well as uncertainties about clinical diagnosis and [...]

Little is known about variations in the levels of access and satisfaction within the disabled Medicare population. Based on the Medicare Current Beneficiary Survey (MCBS), beneficiaries under 65 years of age were classified by original reason for disability (mental versus physical). Those with a mental disability were less likely to have a private physician as a usual source; were less satisfied with the overall quality of care, availability of after-hours care, followup care, and coordination of care, and were more likely to report unmet need, owing in large part to supply barriers. Implications for the current delivery system and for design of managed care programs are discussed., INTRODUCTION The Medicare population under 65 years of age includes individuals who have been receiving Social Security disability insurance benefits for 24 months (disabled workers), persons with end stage renal [...]

This article examines Medicare access, use, and satisfaction before and after implementation of the Medicare Fee Schedule (MFS), based on 3 years of data from the Medicare Current Beneficiary Survey [...]

This article employs a quasi-experimental, pre/post comparison group design to determine whether rural hospital closures (n=11) have had a detrimental impact on access to inpatient and outpatient care for the Medicare population. Closure areas experienced a significant decrease in medical admissions, although admission rates remained higher than in comparison areas. Physician services were not found to substitute for inpatient services following a closure. No adverse impacts on mortality were observed Patients in closure areas were more likely to be admitted to urban teaching hospitals following the closure of their local hospital, INTRODUCTION When a rural hospital closes, concerns are raised about the availability and accessibility of alternative sources of inpatient and emergency care. The number of rural hospital closures increased substantially [...]

The 1988 physicians' practice costs and income survey (PPCIS) collected detailed costs, revenues, and incomes data for a sample of 3,086 physicians. These data are utilized to update the Health Care Financing Administration (HCFA) cost shares used in calculating the medicare economic, index (MEI) and the geographic practice cost index (GPCI). Cost shares were calculated for the national sample, for 16 specialty groupings, for urban and rural areas, and for 9 census divisions. Although statistical tests reveal that cost shares differ across specialties and geographic areas, sensitivity analysis shows that these differences are small enough to have trivial effects in computing the MEI and GPCI. These results may inform policymakers on one aspect of the larger issue of whether physician payments should vary by geographic location or specialty., INTRODUCTION The Medicare fee schedule, phased in beginning January 1, 1992, restructured payment:3 to physicians according to nationally uniform relative values for physician services and a nationally uniform conversion factor. [...]

Objective. To examine implementation of the Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) programs, enacted in 1988. The article summarizes the origin of the QMB and SLMB [...]

• Various methods for estimating the cost of mandated mental health benefits have been devised, each resulting in substantially different estimates. These methods neglect to distinguish between the two components of cost to the insurer: social cost (due to increased utilization) and shifted cost (from other sources of payment). We apply a method we developed for estimating the two types of costs of mandates for outpatient mental health services that integrates data from insurers with information from the literature on financing of mental health services. We applied our method to legislation recently proposed in Massachusetts that would double the mandated minimum benefit level from $500 to $1,000. We expect payments by the largest carrier in the state to increase by a factor of 1.65. More than half of this increase represents shifted costs rather than new costs to society.

Prologue:Nurses and physicians have a long history of cooperation and conflict in carrying out their respective roles on behalf of the patient This relationship has evolved in a variety of settings and over a multitude of issues that sometimes bind and sometimes divide the interests of these medical care professionals. In this context, one of the more difficult relationships revolves around the delivery of anesthesia services. The American Association of Nurse Anesthetists (AANA) is persuaded that a series of developments in recent years indicate the American Society of Anesthesiologists (ASA) and its physician members are actively attempting to eliminate the position of certified registered nurse anesthetist (CRNA) and gain full control of the practice of anesthesia. The ASA, of course, flatly rejects this assertion. In this article, researchers Jerry Cromwell and Margo Rosenbach address some of the central economic questions around the payment of anesthesia services. They amplify these issues in a DataWatch on anesthesia practice patterns, on page 118. Both of these papers derived from a study the authors undertook for the Health Care Financing Administration (HCFA). HCFA is in the process of creating a fee schedule under which Medicare will pay all CRNAs, as directed by Congress in the Omnibus Budget Reconciliation Act of 1986. Currently CRNAs are usually on salaries and do not bill Medicare directly for the anesthesia services they provide. Under the new fee schedule, CRNAs must accept assignment in all instances. Cromwell, who holds a doctorate in economics from Harvard University, is vice-president of the Center for Health Economics Research, a Boston-area based research organization that analyzes and evaluates federal health programs. Rosenbach holds a doctorate in social science research from Brandeis University. She has concentrated on the study of anesthesia and a range of other physician payment issues in her time at the center.

• Psychiatric hospitals and certain distinct part psychiatric units of general hospitals are currently exempt from diagnosis related group (DRG)—based payment under Medicare's prospective payment system (PPS), in large part due to concern about the degree to which such payment would match historical costs for these facilities. This communication simulates DRG-based payments for psychiatric admissions to general hospitals under the PPS and also under a modified version of the PPS. Two major types of modifications are made: (1) an increase in the role of outlier payments and (2) a restructuring of the DRG classification to allow for a difference in the basic payment rate, depending on whether or not care is provided in a facility that is currently exempt. When compared with cost data from just before the start of the PPS, the simulation results show the degree to which these hypothetical modifications will decrease the systematic risk of general hospitals with exempt units from receiving payments that fall short of costs.