Alternative approaches to valuing intangible health losses: the evidence for multiple sclerosis.

This study uses both risk-risk and risk-dollar approaches to assess intangible health losses associated with multiple sclerosis (MS). Using an estimation approach that adjusts for potential perceptional biases that may effect the expressed risk tradeoffs, we estimated parameters of the utility function of persons with and without MS as well as the degree of subjects" overestimation of the probability of obtaining MS. The sample included subjects from the general population and persons with MS. We found that marginal utility of income is lower in the state with MS than without it. However, the difference in marginal in two states was greater for persons without MS than for those with the disease. Persons with MS overestimated the probability of acquiring MS to a greater extent than did persons within MS. Correcting for overestimation of this probability, the value of intangible loss of a statistical case of MS derived from responses of the general population was US$350,000 to US$500.000. Persons with MS were willing to pay somewhat more than this (D80,118,J17).

Hospital credentialing and quality of care.

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

The impact of TennCare on patient satisfaction with care.

OBJECTIVE: To measure the level of satisfaction with care by Medicaid-eligible patients before and after implementation of a mandatory managed care plan known as TennCare. STUDY DESIGN: We used multivariate logit analysis of survey data to calculate the effects of TennCare on patient satisfaction for TennCare patients compared to those on traditional Medicaid, using North Carolina as a control state. PATIENTS AND METHODS: Patients were respondents to a survey conducted in late 1996 and early 1997 who had been admitted to hospitals in 1993 and 1995 for labor/delivery (n = 986), acute myocardial infarction (n = 457), and head trauma (n = 248). Dependent variables were yes/no responses to satisfaction questions for labor/delivery and 5-category ordered responses for adults. RESULTS: We found no statistically significant differences in satisfaction between TennCare and traditional Medicaid for either pediatric or adult hospital patients. Generally, TennCare recipients had satisfaction levels as good or better than traditional Medicaid recipients. For pediatric care, TennCare odds ratios ranged from 1.00 to 2.17, the latter for satisfaction with care received (P = 0.107). For adult care, odds ratios ranged from 0.77 to 1.23, the latter for satisfaction with cost of care (P = 0.547). For many dimensions of care, lower rates of satisfaction were reported for respondents who were uninsured, less educated, and in poor health. For adult care, blacks or Hispanics tended to be less satisfied with some aspects of care. CONCLUSION: TennCare did not reduce patient satisfaction with care among those who were hospitalized.

Effects of state reforms on health insurance coverage of adults.

States have tried a number of strategies to reduce the growing number of uninsured people. These include Medicaid expansions and various insurance reforms, such as low-cost plans, subsidized insurance products, risk pooling, open enrollment and continuity of coverage requirements, and community rating. Using data from 1989 to 1994, we examine the impact of such policies on health insurance coverage for adults. We find that few state policies have succeeded in increasing health insurance coverage. For those that work, impacts are very modest or are accompanied by adverse effects such as crowdout. Implementing effective state policies to reduce the number of uninsured remains a great challenge.

Bankruptcy risk and state regulation of continuing care retirement communities.

Continuing care retirement communities (CCRCs) often require substantial financial investment from residents, prompting concern about potential losses to residents in the event of a CCRC's bankruptcy. State governments have responded to this concern with varying levels of regulation. Overall, CCRC bankruptcy rates are very low (.3% per year). We found that measures of varying regulation stringency had no effect on indicators of CCRCs' financial performance relating to bankruptcy risk. CCRCs that offer extensive contracts, including unlimited long-term care in addition to housing, have less positive indicators of financial strength than other types of CCRCs. When measured by traditional health care industry standards of financial strength, CCRCs appear less profitable than other types of health care facilities. This raises the question of whether CCRCs can continue to attract the needed capital from private markets and because of that, suggests that their future growth may be limited.

Does removing certificate-of-need regulations lead to a surge in health care spending?

This study assesses the impact of certificate-of-need (CON) regulation for hospitals on various measures of health spending per capita, hospital supply, diffusion of technology, and hospital industry organization. Using a time series cross-sectional methodology, we estimate the net impact of CON policies on costs, supply, technology diffusion, and industry organization, controlling for area characteristics, the presence of other forms of regulation, such as hospital rate-setting, and competition. Mature CON programs are associated with a modest (5 percent) long-term reduction in acute care spending per capita, but not with a significant reduction in total per capita spending. There is no evidence of a surge in acquisition of facilities or in costs following removal of CON regulations. Mature CON programs also result in a slight (2 percent) reduction in bed supply but higher costs per day and per admission, along with higher hospital profits. CON regulations generally have no detectable effect on diffusion of various hospital-based technologies. It is doubtful that CON regulations have had much effect on quality of care, positive or negative. Such regulations may have improved access, but there is little empirical evidence to document this.

Life transitions and health insurance coverage of the near elderly.

OBJECTIVES: This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance? METHODS: The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years. RESULTS: One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage. CONCLUSIONS: Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.

The impact of ancillary services on primary care use and outcomes for HIV/AIDS patients with public insurance coverage.

To better understand the impact of ancillary services on access to primary care, utilization of health services, costs and health status of HIV/AIDS patients, we studied adult HIV/AIDS patients eligible for public insurance for low-income people (Medicaid) in eastern North Carolina. Using primary data from a 1997 survey of such patients linked to Medicaid claims, multivariate logit analysis was used to estimate the effect of receiving housing, legal services and substance abuse treatment and of self-reported failure to obtain transportation and child care services on: (a) adequacy and use of primary care; (b) CD-4 counts; (c) viral load; and (d) self-rated health status. Between two-thirds and four-fifths of patients needing ancillary services obtain them. Receipt of housing and legal services were found to have a positive relationship with access to primary care. Difficulties in obtaining transportation and receipt of substance abuse services had a negative relationship with receipt of adequate primary care. On balance, these findings provide some support for continued public funding for various ancillary services to improve patient access to needed primary care. At current funding levels, not all patients needing help appear able to obtain such services.

Continuing care retirement communities: prospects for reducing institutional long-term care.

Continuing care retirement communities (CCRCs) combine housing and long-term care (LTC) services, including personal and nursing home care. The amount of LTC that is prepaid varies by type of CCRC, with one-third offering extensive (fully prepaid) contracts for LTC. CCRCs are a potentially promising model for LTC delivery because they offer a full continuum of services and can substitute less expensive supportive care for institutional care. Using data on CCRCs, we tested one central hypothesis: Provision of supportive services, particularly when combined with capitation, reduces use of nursing home care. To test this hypothesis, we studied the effect of various contract types for LTC services offered by CCRCs and provision of support services on utilization of nursing home and personal care units. Compared with other types of CCRCs, those offering completely prepaid LTC coverage reduced use of nursing home care by 13 percent and personal care by 5 percent. CCRCs with prepaid LTC coverage did not use more stringent health screening at entry, so "cream-skimming" does not appear to explain this result. However, affordability is an important issue: CCRC residents with extensive contracts were wealthier than were other CCRC residents.

Effects of Tennessee Medicaid managed care on obstetrical care and birth outcomes.

A comparative study was conducted in two neighboring states, Tennessee and North Carolina, to determine whether Medicaid managed care (implemented in Tennessee as TennCare) affected prenatal care, care patterns at labor-delivery, and birth outcomes. A pre- and post-design coupled with a difference-in-difference approach--using North Carolina as a control--was used to assess TennCare's effects for all births and for three categories of high-risk mothers (under age eighteen, unwed, or living in high poverty areas). Data from 328,296 singleton births in birth files and matched birth-death files for 1993 and 1995 in both states were used to analyze a number of variables related to maternal behavior during pregnancy, utilization of care before and after labor-delivery, patterns of obstetrical care at delivery, and birth outcomes. Under TennCare, Tennessee mothers were relatively more likely to obtain no prenatal care or to wait and initiate third trimester care as compared to those in North Carolina. Relative utilization of specific prenatal procedures declined, Apgar scores fell very slightly, and birth abnormalities increased in the poverty subsample. TennCare had no significant effect on infant mortality. Utilization reductions in obstetrical services were achieved with apparent spillovers to non-TennCare births, but without adverse effects overall. TennCare was neither a panacea nor an unmitigated disaster. It is a model worth examining, but not uncritically.

Physician participation and nonparticipation in Medicaid managed care: the TennCare experience.

BACKGROUND: TennCare is a significant state health reform effort, channeling all Medicaid recipients into managed care. We examined physician attitudes about TennCare. METHODS: In 1997, we surveyed a stratified random sample of Tennessee physicians using predominantly Likert-type scale questions. All physicians surveyed were involved in patient care and were selected from seven specialties: general practice, family practice, general internal medicine, obstetrics/gynecology, neurosurgery, general surgery, and pediatrics. We asked about participation, satisfaction, perceptions of quality, and appropriateness of care. RESULTS: Major reasons for nonparticipation included bureaucracy and low compensation. Overall, dissatisfaction with TennCare was high (72% not at all or not very satisfied), relating to reimbursement issues and constraints on obtaining services, particularly pharmaceuticals. More physicians (45.9%) thought quality had declined under TennCare than believed it improved (12.6%). CONCLUSIONS: Despite strong negative opinions about TennCare, physician participation is high (85.6%) because of a sense of professional responsibility.

Physicians' attitudes and practices regarding treatment of HIV-infected patients.

We conducted a statewide survey to identify physicians' experiences, attitudes, and practices related to HIV-infected patients. A random sample, stratified by medical specialty (primary care, surgery, emergency medicine), was drawn. Physicians were concerned about contagion and inadequate knowledge to care for HIV-infected patients; 40% reported refusing or referring new HIV-infected patients. Differences across medical specialty and respondents' interest in various medical education topics to remedy knowledge deficits are discussed.

Economic evaluations of HIV treatment and health research with people diagnosed with HIV infection and co-occurring mental health and substance use disorders.

This paper describes the research challenges involved in measuring costs in economic evaluations of patients who are coping simultaneously with HIV/AIDS and co-occurring mental health and substance abuse disorders-especially in multi-site studies. We describe the general issues that arise in measuring costs for this population and suggest some operational solutions for their resolution, drawing from our experience in a recent multi-site health services research study focused on this population. We show that while reliance on patient self-report data may be unavoidable to provide a common denominator in multi-site studies, there are also some practical ways of improving the accuracy of such data and the cost estimates that result from them. We also provide readers with a means for securing the data collection instruments developed for the cost component of this study in the hope that these may serve as templates for researchers doing similar work.

Medicaid, managed care, and the care of patients hospitalized for acute myocardial infarction.

BACKGROUND: TennCare, beginning in January 1994, channeled all Medicaid-eligible patients into managed care while expanding Medicaid coverage to large numbers of previously uninsured patients. We assessed the impact of TennCare on (1) coronary revascularization of patients who had had an acute myocardial infarction (AMI), (2) the likelihood of the patient having a usual provider of care after discharge from the hospital, and (3) health and functional status 1 to 3 years after the index AMI. METHODS AND RESULTS: With the use of 1996 to 1997 survey data from 438 patients hospitalized for AMI in 1993 and 1995 who were under age 65 years at the index admission, multivariate analysis was used to calculate effects of TennCare on utilization and outcomes. TennCare patients were as likely as privately insured patients to have received coronary revascularization within 30 days of the index AMI (odds ratio 0.87, P =.69). Persons enrolled in TennCare and in traditional Medicaid who received a revascularization procedure were much less likely to have received coronary angioplasty than coronary bypass surgery than were the privately insured (TennCare: odds ratio 0.37, P =.05; Medicaid: odds ratio 0.28, P =.08). Virtually all TennCare enrollees (94%) reported having a usual provider of care in the year before the survey versus 85% for privately insured patients with AMI in 1995 (P =.05). On health and functional status, TennCare enrollees overall fared as well as those with private insurance. CONCLUSIONS: Our results suggest that TennCare brought patients who otherwise would have been uninsured or enrolled in Medicaid into the medical mainstream, measured both in terms of utilization of services and health and functional status.

Hospital credentialing for laparoscopic cholecystectomy: is stricter better?

OBJECTIVE: Hospital credentialing standards for laparoscopic cholecystectomy were established to improve surgical outcomes, but standards vary by hospital. We hypothesized that more stringent credentialing would result in better outcomes. DESIGN: Univariate and multivariate logistic analyses were performed using a 1996 survey on hospital credentialing practices. Surgical-outcome data were obtained from statewide hospital discharge abstracts and hospital chart reviews. Multivariate logistic analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on operative and postoperative outcomes (including death), controlling for patient and hospital characteristics. SETTING: Short-stay community hospitals performing laparoscopic cholecystectomy. PATIENTS: Statewide hospital discharge data included 1995 inpatient discharges for laparoscopic cholecystectomy. Medical-records review included 843 laparoscopic cholecystectomy patients selected from 14 North Carolina hospitals with widely different credentialing practices. RESULTS: Surgical complications from laparoscopic cholecystectomies appeared unrelated to stringency of the hospital credentialing environment. Important factors predicting complications included hospital volume and other hospital characteristics such as the number of registered nurses per patient day. CONCLUSIONS: Given current levels of training, performance, and credentialing standards, tightening of credentialing practices may not improve patient outcomes for laparoscopic cholecystectomy.